Provider Demographics
NPI:1770818965
Name:HANSEN, KIRK WAYNE (PT)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:WAYNE
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-1563
Mailing Address - Country:US
Mailing Address - Phone:801-625-9346
Mailing Address - Fax:801-625-9335
Practice Address - Street 1:3350 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-1563
Practice Address - Country:US
Practice Address - Phone:801-625-9346
Practice Address - Fax:801-625-9335
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4739083-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist