Provider Demographics
NPI:1356568661
Name:HANSON, NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 RYAN DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-9687
Mailing Address - Country:US
Mailing Address - Phone:503-399-1262
Mailing Address - Fax:503-485-3738
Practice Address - Street 1:2925 RYAN DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-9687
Practice Address - Country:US
Practice Address - Phone:503-399-1262
Practice Address - Fax:503-485-3738
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1745232085R0202X, 2085R0204X
CAA984162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356568661Medicaid
CA00A984160OtherBS OF CA
OR500698850Medicaid
CAGI132ZMedicare PIN
CA00A984160OtherBS OF CA