Provider Demographics
NPI:1508114810
Name:HANSEN, CARL RICHARD II (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RICHARD
Last Name:HANSEN
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4960
Mailing Address - Country:US
Mailing Address - Phone:952-920-6100
Mailing Address - Fax:
Practice Address - Street 1:4601 EXCELSIOR BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4960
Practice Address - Country:US
Practice Address - Phone:952-920-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261242084B0040X, 2084P0005X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND73263Medicare UPIN