Provider Demographics
NPI:1437121894
Name:HANSON, COLLEEN FAYE (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:FAYE
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 1:120 N C AVE
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2410
Mailing Address - Country:US
Mailing Address - Phone:307-864-5534
Mailing Address - Fax:307-864-9470
Practice Address - Street 1:120 N C AVE
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2410
Practice Address - Country:US
Practice Address - Phone:307-864-5534
Practice Address - Fax:307-864-9470
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1112CH98MOtherWY CONTROLLED SUBSTANCE #
WY170OtherWY MEDICAL LICENSE #
WYMH0400349OtherDEA
WYMH0400349OtherDEA
WYW308767Medicare ID - Type Unspecified