Provider Demographics
NPI:1023423316
Name:HANSON, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:HANSON
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 1:519 KARL DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2543
Mailing Address - Country:US
Mailing Address - Phone:216-486-5135
Mailing Address - Fax:
Practice Address - Street 1:519 KARL DR
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-2543
Practice Address - Country:US
Practice Address - Phone:216-486-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0058141Medicaid