Provider Demographics
NPI:1194732669
Name:HANSEN, GLENN A (DPM)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:A
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2331 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5267
Mailing Address - Country:US
Mailing Address - Phone:920-499-1177
Mailing Address - Fax:920-499-5398
Practice Address - Street 1:2331 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5267
Practice Address - Country:US
Practice Address - Phone:920-499-1177
Practice Address - Fax:920-499-5398
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI403-025213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43217500Medicaid
WIT62116Medicare UPIN
WI1020840001Medicare NSC
WI43217500Medicaid