Provider Demographics
NPI:1760768147
Name:HANSON, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 MILLER TRUNK HWY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5633
Mailing Address - Country:US
Mailing Address - Phone:218-727-8157
Mailing Address - Fax:
Practice Address - Street 1:1201 MILLER TRUNK HWY
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5633
Practice Address - Country:US
Practice Address - Phone:218-727-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119629183500000X
WI15795-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist