Provider Demographics
NPI:1457976045
Name:HANSON, TYSON
Entity Type:Individual
Prefix:MR
First Name:TYSON
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 WIND RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-2101
Mailing Address - Country:US
Mailing Address - Phone:208-521-1837
Mailing Address - Fax:
Practice Address - Street 1:1496 N 1070 E
Practice Address - Street 2:
Practice Address - City:SHELEY
Practice Address - State:ID
Practice Address - Zip Code:83274
Practice Address - Country:US
Practice Address - Phone:208-521-1837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child