Provider Demographics
NPI:1710911516
Name:HANSEN, MATTHEW LERON (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LERON
Last Name:HANSEN
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:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:2940 E BANNER GATEWAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-964-2908
Practice Address - Fax:480-833-2136
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35613207XX0005X, 207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830006OtherMEDICARE NSC ANTHEM
AZ5550830007OtherMEDICARE NSC DV
AZ5550830010OtherMEDICARE NSC GILBERT
AZ5550830004OtherMEDICARE NSC PV
AZP00346251OtherRR MEDICARE
AZ112448Medicaid
AZ5550830001OtherMEDICARE NSC SCW
AZ5550830008OtherMEDICARE NSC SWV
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830008OtherMEDICARE NSC SWV