Provider Demographics
NPI:1962938217
Name:HANSEN, BRADY (DO)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10972 JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-3757
Mailing Address - Country:US
Mailing Address - Phone:801-592-3198
Mailing Address - Fax:
Practice Address - Street 1:51ST MEDICAL GROUP
Practice Address - Street 2:UNIT 2060
Practice Address - City:APO
Practice Address - State:CA
Practice Address - Zip Code:46234
Practice Address - Country:US
Practice Address - Phone:801-592-3198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
HI2048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program