Provider Demographics
NPI:1013786425
Name:HANSEN, GLEN THOMAS (PHD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:THOMAS
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4665 GOLDENROD LN N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2493
Mailing Address - Country:US
Mailing Address - Phone:161-275-1210
Mailing Address - Fax:
Practice Address - Street 1:10581 ROSELLE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1519
Practice Address - Country:US
Practice Address - Phone:858-258-9493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician