Provider Demographics
NPI:1396336434
Name:HANSON, NOAH JACK
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:JACK
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 1:13562 435TH ST SW
Mailing Address - Street 2:
Mailing Address - City:FERTILE
Mailing Address - State:MN
Mailing Address - Zip Code:56540-9102
Mailing Address - Country:US
Mailing Address - Phone:218-280-5781
Mailing Address - Fax:
Practice Address - Street 1:306 N MILL ST
Practice Address - Street 2:
Practice Address - City:FERTILE
Practice Address - State:MN
Practice Address - Zip Code:56540-4330
Practice Address - Country:US
Practice Address - Phone:218-945-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor