Provider Demographics
NPI:1518198860
Name:HANSEN, ETHAN JARED (DPT)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:JARED
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S 6TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:AZ
Practice Address - Zip Code:86046-0110
Practice Address - Country:US
Practice Address - Phone:928-635-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist