Provider Demographics
NPI:1104558568
Name:HANSEN, CHRISTINE DANIELLE (PA)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:DANIELLE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-302-9342
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:11035 KARCHER RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-8200
Practice Address - Country:US
Practice Address - Phone:208-302-6650
Practice Address - Fax:208-302-6655
Is Sole Proprietor?:No
Enumeration Date:2022-06-25
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant