Provider Demographics
NPI:1245548825
Name:HANSEN, JEROME L (PA)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 B CEDAR TREE PLACE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-0530
Mailing Address - Country:US
Mailing Address - Phone:561-706-3954
Mailing Address - Fax:
Practice Address - Street 1:2155 W MUSTANG BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465
Practice Address - Country:US
Practice Address - Phone:352-746-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105468363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical