Provider Demographics
NPI:1710149794
Name:HANSON, NICHOLAS GARY (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GARY
Last Name:HANSON
Suffix:
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 1:24 S 1100 E STE 310
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1500
Mailing Address - Country:US
Mailing Address - Phone:801-328-1260
Mailing Address - Fax:801-350-4361
Practice Address - Street 1:24 S 1100 E STE 310
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84102-1500
Practice Address - Country:US
Practice Address - Phone:801-328-1260
Practice Address - Fax:801-350-4361
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT84392901205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10161981OtherPHYSICIANS DOB