Provider Demographics
NPI:1518721695
Name:HANSEN, IAN (FNP)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 HARRISON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2038
Mailing Address - Country:US
Mailing Address - Phone:385-626-6386
Mailing Address - Fax:
Practice Address - Street 1:1386 S 1025 W
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9868
Practice Address - Country:US
Practice Address - Phone:801-866-2754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9100218-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily