Provider Demographics
NPI:1245306166
Name:HANSEN, PAMELA A (PA-C)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:A
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1315 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-1447
Mailing Address - Country:US
Mailing Address - Phone:815-539-1422
Mailing Address - Fax:815-539-1436
Practice Address - Street 1:1315 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1447
Practice Address - Country:US
Practice Address - Phone:815-539-1422
Practice Address - Fax:815-539-1436
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R78362Medicare UPIN