Provider Demographics
NPI:1407842057
Name:HANSON, CYNTHIA LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LYNN
Last Name:HANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 E BELTLINE AVE NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-4598
Mailing Address - Country:US
Mailing Address - Phone:616-363-0055
Mailing Address - Fax:616-363-5180
Practice Address - Street 1:1525 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4598
Practice Address - Country:US
Practice Address - Phone:616-363-0055
Practice Address - Fax:616-363-5180
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002660363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N66350Medicare ID - Type Unspecified