Provider Demographics
NPI:1437398419
Name:HANSON, LISA (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HANSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 N BUTLER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6430
Mailing Address - Country:US
Mailing Address - Phone:505-326-0064
Mailing Address - Fax:
Practice Address - Street 1:3501 N BUTLER AVE STE 101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6430
Practice Address - Country:US
Practice Address - Phone:505-326-0064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016903225100000X
NM4043225100000X
SC6540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist