Provider Demographics
NPI:1922657501
Name:HANSON, CHASE WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:WILLIAM
Last Name:HANSON
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 1:2210 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7430
Mailing Address - Country:US
Mailing Address - Phone:208-522-3355
Mailing Address - Fax:208-522-6019
Practice Address - Street 1:2210 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7430
Practice Address - Country:US
Practice Address - Phone:208-522-3355
Practice Address - Fax:208-522-6019
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant