Provider Demographics
NPI:1710947130
Name:HANSON, GLEN D (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:D
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 1:210 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:50849-9544
Mailing Address - Country:US
Mailing Address - Phone:641-743-2517
Mailing Address - Fax:
Practice Address - Street 1:210 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IA
Practice Address - Zip Code:50849-9544
Practice Address - Country:US
Practice Address - Phone:641-743-2517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22294207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA01536Medicare UPIN