Provider Demographics
NPI:1124061619
Name:HANSEN, DOUGLAS ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:801 YORK ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4630
Practice Address - Country:US
Practice Address - Phone:920-663-9008
Practice Address - Fax:920-684-1439
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74455-20207ZD0900X, 207ND0900X, 207ZP0102X
FLME122758207ZP0102X
ORMD21809207ZP0102X
WAMD00034088207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134098Medicaid
ORA015OtherTRICARE
WA8416026Medicaid
OR220026417OtherRR MEDICARE
OR134098Medicaid
WAG8861191Medicare PIN
WAG8861191Medicare PIN