Provider Demographics
NPI:1881640233
Name:HANSEN, LORNELL EUGENE II (MD)
Entity Type:Individual
Prefix:
First Name:LORNELL
Middle Name:EUGENE
Last Name:HANSEN
Suffix:II
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 1:3401 S KELLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-6300
Mailing Address - Country:US
Mailing Address - Phone:605-274-0217
Mailing Address - Fax:605-275-6398
Practice Address - Street 1:3401 S KELLEY AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6300
Practice Address - Country:US
Practice Address - Phone:605-274-0217
Practice Address - Fax:605-275-6398
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30920207Q00000X
SD4768202K00000X, 207Q00000X
MN51491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00016846Medicare PIN
G22391Medicare UPIN
SDS41297Medicare PIN
SD080192446Medicare PIN