Provider Demographics
NPI:1396431672
Name:HANSEN, MELISSA MARSHALL
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARSHALL
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10205 SW 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-7365
Mailing Address - Country:US
Mailing Address - Phone:352-283-0095
Mailing Address - Fax:
Practice Address - Street 1:10205 SW 104TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-7365
Practice Address - Country:US
Practice Address - Phone:352-283-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT826632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology