Provider Demographics
NPI:1932210317
Name:HANSEN, CARL W (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:W
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 1:204 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-9449
Mailing Address - Country:US
Mailing Address - Phone:715-483-3221
Mailing Address - Fax:
Practice Address - Street 1:204 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9449
Practice Address - Country:US
Practice Address - Phone:715-483-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN64Q26HAOtherBLUE CROSS MN PRO FEE
HP10546OtherHEALTHPARTNERS
0406274OtherMEDICA
WI31162400Medicaid
MN27G34HAOtherBLUE CROSS MN FACILITY
NA9030224004OtherPREFERREDONE
WI31162400Medicaid