Provider Demographics
NPI:1679592372
Name:HANSEN, JOHN GREGORY JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGORY
Last Name:HANSEN
Suffix:JR
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 1:13907 W CAMINO DEL SOL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-4405
Mailing Address - Country:US
Mailing Address - Phone:623-584-4695
Mailing Address - Fax:623-298-6708
Practice Address - Street 1:13907 W CAMINO DEL SOL
Practice Address - Street 2:SUITE 101
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-4405
Practice Address - Country:US
Practice Address - Phone:623-584-4695
Practice Address - Fax:623-298-6708
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24172174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ340018047OtherRAILROAD MEDICARE
AZ1Z5256OtherHEALTHNET OF AZ
AZ434712Medicaid
AZAZ0867880OtherBLUE CROSS BLUE SHIELD AZ
63360Medicare ID - Type Unspecified
AZ434712Medicaid