Provider Demographics
NPI:1942256169
Name:HANSON, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:HANSON
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 1:590 MCDONALD DR
Mailing Address - Street 2:
Mailing Address - City:INCLINE VILLAGE
Mailing Address - State:NV
Mailing Address - Zip Code:89451-9133
Mailing Address - Country:US
Mailing Address - Phone:612-384-8891
Mailing Address - Fax:
Practice Address - Street 1:930 TAHOE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-9451
Practice Address - Country:US
Practice Address - Phone:775-833-2929
Practice Address - Fax:775-833-0277
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13177207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN566717800Medicaid
MN566717800Medicaid