Provider Demographics
NPI:1013906387
Name:HANSEN, TERRY WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:WAYNE
Last Name:HANSEN
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 1:703 STERLING WATER CT
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-7707
Mailing Address - Country:US
Mailing Address - Phone:770-266-7954
Mailing Address - Fax:
Practice Address - Street 1:1027 BATEMAN DR
Practice Address - Street 2:SUITE B
Practice Address - City:SOCIAL CIRCLE
Practice Address - State:GA
Practice Address - Zip Code:30025-5025
Practice Address - Country:US
Practice Address - Phone:770-464-2048
Practice Address - Fax:770-464-9995
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG65732Medicare UPIN
GA08BBRLLMedicare ID - Type Unspecified