Provider Demographics
NPI:1457840696
Name:HANSON, MARIKO
Entity Type:Individual
Prefix:
First Name:MARIKO
Middle Name:
Last Name:HANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 S 13TH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-4166
Mailing Address - Country:US
Mailing Address - Phone:952-201-8643
Mailing Address - Fax:
Practice Address - Street 1:475 BRICKELL AVE APT 3107
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-2597
Practice Address - Country:US
Practice Address - Phone:952-201-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238677390200000X
FLME1628402084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program