Provider Demographics
NPI:1760810766
Name:HANSON, RANDALL ALAN JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ALAN
Last Name:HANSON
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:293 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2155
Practice Address - Country:US
Practice Address - Phone:770-867-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001293213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7562450001OtherMEDICARE DME PTAN
GAPOD001293OtherGEORGIA STATE BOARD OF PODIATRY EXAMINERS