Provider Demographics
NPI:1881760551
Name:HANSEN, VINCENT EDWARD
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:EDWARD
Last Name:HANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:VINCENT
Other - Middle Name:EDWARD
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:250 NE 181ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230
Mailing Address - Country:US
Mailing Address - Phone:503-666-8900
Mailing Address - Fax:503-666-8906
Practice Address - Street 1:250 NE 181ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230
Practice Address - Country:US
Practice Address - Phone:503-666-8900
Practice Address - Fax:503-666-8906
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2470OtherCLIA
OR224568Medicaid
OR0000BHHNMMedicare ID - Type Unspecified
C92805Medicare UPIN