Provider Demographics
NPI:1083676332
Name:HANSEN, LISA MA (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MA
Last Name:HANSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 KRISTEN CT
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-9010
Mailing Address - Country:US
Mailing Address - Phone:563-582-3173
Mailing Address - Fax:563-582-3558
Practice Address - Street 1:4200 DODGE ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003-2624
Practice Address - Country:US
Practice Address - Phone:563-582-3458
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI9810Medicare ID - Type Unspecified
IAU40240Medicare UPIN