Provider Demographics
NPI:1982792297
Name:HANSON, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
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 1:100 4TH ST S STE 612
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1940
Mailing Address - Country:US
Mailing Address - Phone:701-235-0561
Mailing Address - Fax:701-235-0330
Practice Address - Street 1:100 4TH ST S STE 612
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1940
Practice Address - Country:US
Practice Address - Phone:701-235-0561
Practice Address - Fax:701-235-0330
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4870207W00000X
MN29226207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11357OtherBLUE SHIELD
MN2M042HAOtherBLUE SHIELD
ND14255Medicaid
ND892822OtherVISION SERVICES
ND892822OtherVISION SERVICES
ND11357Medicare ID - Type Unspecified