Provider Demographics
NPI:1457840696
Name:HANSON, MARIKO
Entity Type:Individual
Prefix:
First Name:MARIKO
Middle Name:
Last Name:HANSON
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 1:303 E MATTHEWS AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3120
Mailing Address - Country:US
Mailing Address - Phone:870-207-7350
Mailing Address - Fax:870-207-0575
Practice Address - Street 1:303 E MATTHEWS AVE STE 202
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3120
Practice Address - Country:US
Practice Address - Phone:870-207-7350
Practice Address - Fax:870-207-0575
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1628402084N0400X
NC238677390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program