Provider Demographics
NPI:1801875695
Name:HANSEN, RONNELL ALLEN (MD)
Entity type:Individual
Prefix:
First Name:RONNELL
Middle Name:ALLEN
Last Name:HANSEN
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 1:1414 EAST POND ROAD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2879
Mailing Address - Country:US
Mailing Address - Phone:651-528-7243
Mailing Address - Fax:651-493-0083
Practice Address - Street 1:1414 EAST POND ROAD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2879
Practice Address - Country:US
Practice Address - Phone:651-528-7243
Practice Address - Fax:651-493-0083
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN423202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN887950800Medicaid
MNG82625Medicare UPIN
MN300002097Medicare PIN