Provider Demographics
NPI:1245283605
Name:HANSEN-DISPENZA, HEATHER L (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:HANSEN-DISPENZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2965 NE CONNERS AVE STE 127
Mailing Address - Street 2:ST. CHARLES RHEUMATOLOGY
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7753
Mailing Address - Country:US
Mailing Address - Phone:541-706-7735
Mailing Address - Fax:541-706-4806
Practice Address - Street 1:2965 NE CONNERS AVE STE 127
Practice Address - Street 2:ST. CHARLES RHEUMATOLOGY
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7753
Practice Address - Country:US
Practice Address - Phone:541-706-7735
Practice Address - Fax:541-706-4806
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD161426207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17672066Medicaid
I63095Medicare UPIN
NM17672066Medicaid