Provider Demographics
NPI:1760711071
Name:HANSEN, JAN M (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:M
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 DOVE ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3023
Mailing Address - Country:US
Mailing Address - Phone:949-955-3635
Mailing Address - Fax:
Practice Address - Street 1:901 DOVE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3023
Practice Address - Country:US
Practice Address - Phone:949-955-3635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52477174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist