Provider Demographics
NPI:1932262474
Name:HANSON, DAVID JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JEROME
Last Name:HANSON
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 1:2829 UNIVERSITY S DR
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6050
Mailing Address - Country:US
Mailing Address - Phone:701-404-9909
Mailing Address - Fax:877-813-3081
Practice Address - Street 1:2829 UNIVERSITY S DR
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6050
Practice Address - Country:US
Practice Address - Phone:701-404-9909
Practice Address - Fax:877-813-3081
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44547207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN660038700Medicaid
MN050001566Medicare ID - Type Unspecified
MN660038700Medicaid