Provider Demographics
NPI:1598860041
Name:HANSEN, MATTHEW CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHRISTIAN
Last Name:HANSEN
Suffix:
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 1:1160 E 3900 S #1000
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1233
Mailing Address - Country:US
Mailing Address - Phone:801-262-1771
Mailing Address - Fax:801-288-9101
Practice Address - Street 1:1160 E 3900 S #1000
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1233
Practice Address - Country:US
Practice Address - Phone:801-262-1771
Practice Address - Fax:801-288-9101
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT328603-1205207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005521703Medicare PIN