Provider Demographics
NPI:1962113548
Name:WADE-HANSON, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WADE-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 1:10138 W PAYSON RD
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-8441
Mailing Address - Country:US
Mailing Address - Phone:414-759-7445
Mailing Address - Fax:
Practice Address - Street 1:10138 W PAYSON RD
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-8441
Practice Address - Country:US
Practice Address - Phone:414-759-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744R1102X, 246ZB0500X, 2255A2300X, 246ZB0301X
AZD06300831172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744R1102XOther Service ProvidersSpecialistResearch Study
No246ZB0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherBiochemist
No172A00000XOther Service ProvidersDriver
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZB0301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherBiomedical Engineering