Provider Demographics
NPI:1700200789
Name:HANSON, ROSS (PT)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-1807
Mailing Address - Country:US
Mailing Address - Phone:319-462-6882
Mailing Address - Fax:
Practice Address - Street 1:315 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-1807
Practice Address - Country:US
Practice Address - Phone:319-462-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5335225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1212044Medicare PIN
IAI19172Medicare PIN
IAIB1213048Medicare PIN
IAIB1212Medicare PIN
IAI19172048Medicare PIN
IAIB1213Medicare PIN