Provider Demographics
NPI:1629435748
Name:HANSEN, JON C (PA-C)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-1222
Mailing Address - Country:US
Mailing Address - Phone:801-419-5409
Mailing Address - Fax:
Practice Address - Street 1:301 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2630
Practice Address - Country:US
Practice Address - Phone:215-572-3423
Practice Address - Fax:215-572-3411
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant