Provider Demographics
NPI:1588981393
Name:HANSEN, JOHN ROBERT
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:HANSEN
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 1:760 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON HOLE
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9379
Mailing Address - Country:US
Mailing Address - Phone:307-413-4760
Mailing Address - Fax:
Practice Address - Street 1:760 PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:JACKSON HOLE
Practice Address - State:WY
Practice Address - Zip Code:83001-9379
Practice Address - Country:US
Practice Address - Phone:307-413-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor