Provider Demographics
NPI:1932677309
Name:HANSEN, GARRETT
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 NORTHBAY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8859
Mailing Address - Country:US
Mailing Address - Phone:662-213-9099
Mailing Address - Fax:
Practice Address - Street 1:402 NORTHBAY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8859
Practice Address - Country:US
Practice Address - Phone:662-213-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer