Provider Demographics
NPI:1194306670
Name:HANSEN, BRYANT CLAYTON (MD)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:CLAYTON
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 1:1148 AUTUMN RDG NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8805
Mailing Address - Country:US
Mailing Address - Phone:616-443-9793
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST # 9C
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-993-2530
Practice Address - Fax:313-993-7703
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01093349A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program