Provider Demographics
NPI:1689303802
Name:HANSON, SOPHIA LYNN (PA)
Entity Type:Individual
Prefix:MS
First Name:SOPHIA
Middle Name:LYNN
Last Name:HANSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8366 FAIRCHILD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6121
Mailing Address - Country:US
Mailing Address - Phone:763-248-6378
Mailing Address - Fax:
Practice Address - Street 1:15245 BLUEBIRD ST NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3538
Practice Address - Country:US
Practice Address - Phone:763-587-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant