Provider Demographics
NPI:1114024650
Name:DWAYNE M. HANSEN MD PLLC
Entity type:Organization
Organization Name:DWAYNE M. HANSEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-656-8442
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0185
Mailing Address - Country:US
Mailing Address - Phone:208-656-8442
Mailing Address - Fax:208-656-8453
Practice Address - Street 1:381 EAST 4TH NORTH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-656-8442
Practice Address - Fax:208-656-8453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty