Provider Demographics
NPI:1104414754
Name:HANSEN, MILES DOUGLAS JR (ATC)
Entity type:Individual
Prefix:MR
First Name:MILES
Middle Name:DOUGLAS
Last Name:HANSEN
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DALEY RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-3225
Mailing Address - Country:US
Mailing Address - Phone:845-546-2286
Mailing Address - Fax:
Practice Address - Street 1:10 DALEY RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-3225
Practice Address - Country:US
Practice Address - Phone:845-546-2286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0021762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer