Provider Demographics
NPI:1942369707
Name:HANSEN, AVA MARILYN (MD)
Entity Type:Individual
Prefix:DR
First Name:AVA
Middle Name:MARILYN
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 E 73RD ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3556
Mailing Address - Country:US
Mailing Address - Phone:212-861-9000
Mailing Address - Fax:212-472-6883
Practice Address - Street 1:133 E 73RD ST
Practice Address - Street 2:SUITE 209
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3556
Practice Address - Country:US
Practice Address - Phone:212-861-9000
Practice Address - Fax:212-472-6883
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01427389Medicaid
NYF58432Medicare UPIN
NY55H12Medicare ID - Type Unspecified