Provider Demographics
NPI:1124439609
Name:HANSEN, SHAUN RYAN (LMP)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:RYAN
Last Name:HANSEN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 ERSKINE WAY SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4427
Mailing Address - Country:US
Mailing Address - Phone:808-250-0423
Mailing Address - Fax:
Practice Address - Street 1:4920 ERSKINE WAY SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4427
Practice Address - Country:US
Practice Address - Phone:808-250-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-18
Last Update Date:2014-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60389663225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist