Provider Demographics
NPI:1568418770
Name:HANSEN, PAUL DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DAVID
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 S BOAS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3611
Mailing Address - Country:US
Mailing Address - Phone:707-974-6093
Mailing Address - Fax:
Practice Address - Street 1:3751 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-525-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006880225100000X
CAPT39427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS78281Medicare ID - Type Unspecified