Provider Demographics
NPI:1437479920
Name:ERIC HANSEN MD PC
Entity Type:Organization
Organization Name:ERIC HANSEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-789-8881
Mailing Address - Street 1:150 ARROWHEAD DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9353
Mailing Address - Country:US
Mailing Address - Phone:307-789-8881
Mailing Address - Fax:307-789-6470
Practice Address - Street 1:150 ARROWHEAD DR
Practice Address - Street 2:SUITE 2
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9353
Practice Address - Country:US
Practice Address - Phone:307-789-8881
Practice Address - Fax:307-789-6470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6429A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119741000Medicaid
WYW310473OtherMEDICARE ID-TYPE UNSPECIFIED
WY119741000Medicaid