Provider Demographics
NPI:1407386667
Name:HANSEN, RYAN (OD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 E ROCKTON RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9076
Mailing Address - Country:US
Mailing Address - Phone:815-242-9886
Mailing Address - Fax:815-242-9809
Practice Address - Street 1:4775 E ROCKTON RD UNIT A
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9076
Practice Address - Country:US
Practice Address - Phone:815-242-9886
Practice Address - Fax:815-242-9809
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-011291152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist