Provider Demographics
NPI:1619211299
Name:HANSON, TIMOTHY MARCUS (PTA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MARCUS
Last Name:HANSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1503
Mailing Address - Country:US
Mailing Address - Phone:608-356-3420
Mailing Address - Fax:608-355-3333
Practice Address - Street 1:1414 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1503
Practice Address - Country:US
Practice Address - Phone:608-356-3420
Practice Address - Fax:608-355-3333
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1966-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant