Provider Demographics
NPI:1437327475
Name:GLENN A. HANSEN, D.P.M.
Entity Type:Organization
Organization Name:GLENN A. HANSEN, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-499-1177
Mailing Address - Street 1:2331 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5267
Mailing Address - Country:US
Mailing Address - Phone:920-499-1177
Mailing Address - Fax:920-499-5398
Practice Address - Street 1:2331 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5267
Practice Address - Country:US
Practice Address - Phone:920-499-1177
Practice Address - Fax:920-499-5398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI403-025261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43217500Medicaid
WI43217500Medicaid
WI84548Medicare PIN
WI1020840001Medicare NSC