Provider Demographics
NPI:1871686444
Name:HANSEN, MATTHEW VERNON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:VERNON
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 TRAILWAY PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247
Mailing Address - Country:US
Mailing Address - Phone:210-722-2274
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST WEST
Practice Address - Street 2:12 MEDICAL GROUP
Practice Address - City:RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4801
Practice Address - Country:US
Practice Address - Phone:210-652-9836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1025979363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical