Provider Demographics
NPI:1063522597
Name:HANSON, JASON MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MATTHEW
Last Name:HANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12255 DE PAUL DR STE 830N
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:314-291-5307
Mailing Address - Fax:314-291-0838
Practice Address - Street 1:12255 DE PAUL DR STE 830N
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-291-5307
Practice Address - Fax:314-291-0838
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103004207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO002013172OtherPTAN
MOF99201Medicare UPIN
MO002013172OtherPTAN