Provider Demographics
NPI:1528053790
Name:HANSEN, REGAN BENNETT (MD)
Entity type:Individual
Prefix:DR
First Name:REGAN
Middle Name:BENNETT
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WARNER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-3523
Mailing Address - Fax:208-746-8741
Practice Address - Street 1:320 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:208-746-8741
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7862207X00000X
WAMD00037759207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID10005614OtherREGENCE
WA8245110Medicaid
ID33399OtherBLUE CROSS OF IDAHO
ID805498200Medicaid
ID33399OtherBLUE CROSS OF IDAHO
ID10005614OtherREGENCE
WA8245110Medicaid
WAGAB12080Medicare PIN