Provider Demographics
NPI:1356367155
Name:HANSEN, AVON I
Entity type:Individual
Prefix:
First Name:AVON
Middle Name:I
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AVON
Other - Middle Name:IONE
Other - Last Name:CHILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:UNIT 28216 BOX HOHENFELS
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09173-8216
Mailing Address - Country:US
Mailing Address - Phone:314-590-3316
Mailing Address - Fax:
Practice Address - Street 1:UNIT 28216 BOX HOHENFELS
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09173-8216
Practice Address - Country:US
Practice Address - Phone:314-590-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004255363A00000X, 363AM0700X, 363A00000X
CA363A00000X
COPA.0003815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P20596Medicare UPIN