Provider Demographics
NPI:1285080853
Name:HANSEN, BLAKE (DO)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HANSEN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 W HIGHLAND KNOLLS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-6255
Mailing Address - Country:US
Mailing Address - Phone:479-337-7521
Mailing Address - Fax:479-888-1408
Practice Address - Street 1:4803 W HIGHLAND KNOLLS RD STE 150
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-6255
Practice Address - Country:US
Practice Address - Phone:479-337-7521
Practice Address - Fax:479-888-1408
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-12376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program