Provider Demographics
NPI:1851566947
Name:HANSEN, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-652-1381
Mailing Address - Fax:
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2353
Practice Address - Country:US
Practice Address - Phone:702-671-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD191050207RC0200X, 207RP1001X
NV20436207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1851566947Medicaid
IA1851566947Medicaid
NV20436OtherMEDICAL LICENSE