Provider Demographics
NPI:1104916543
Name:HANSEN, ORRIN BLAKE (APRN)
Entity type:Individual
Prefix:MR
First Name:ORRIN
Middle Name:BLAKE
Last Name:HANSEN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATT CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-543-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1175 E 50 S STE 241
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2849
Practice Address - Country:US
Practice Address - Phone:801-492-5999
Practice Address - Fax:801-418-0897
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT282878-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1104916543Medicaid
UT000069706Medicare PIN