Provider Demographics
NPI:1396302345
Name:HANSON, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 PIONEER TRL
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1167
Mailing Address - Country:US
Mailing Address - Phone:952-368-2325
Mailing Address - Fax:952-368-2328
Practice Address - Street 1:15052 GLEASON PATH STE 104
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7199
Practice Address - Country:US
Practice Address - Phone:952-432-5889
Practice Address - Fax:952-432-1878
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist