Provider Demographics
NPI:1760540801
Name:HANSON, CLYDE ARTHUR (DO)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:ARTHUR
Last Name:HANSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1803
Mailing Address - Country:US
Mailing Address - Phone:205-245-5551
Mailing Address - Fax:208-245-2262
Practice Address - Street 1:600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9560
Practice Address - Country:US
Practice Address - Phone:360-346-2299
Practice Address - Fax:360-346-2157
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-231207P00000X
WAOP60768791207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805770200Medicaid
ID000010028719OtherREGENCE BS IDAHO
WA8434847Medicaid
WA141315OtherWA LABOR & INDUSTRIES
601415900OtherDEEIOC
IDS3168OtherBC OF ID
ID1373881Medicare Oscar/Certification
IDS3168OtherBC OF ID
ID000010028719OtherREGENCE BS IDAHO