Provider Demographics
NPI:1255885927
Name:HANSEN, JESSE HYRUM (CRNA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:HYRUM
Last Name:HANSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10604 E NATIVE ROSE TRL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747-6020
Mailing Address - Country:US
Mailing Address - Phone:530-331-0456
Mailing Address - Fax:
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2434
Practice Address - Country:US
Practice Address - Phone:208-750-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95099542163W00000X
ID62297367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse