Provider Demographics
NPI:1538213137
Name:HANSON, PHILLIP MARTIN (PA)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:MARTIN
Last Name:HANSON
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:PO BOX 64575
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-0575
Mailing Address - Country:US
Mailing Address - Phone:910-630-1112
Mailing Address - Fax:910-425-1110
Practice Address - Street 1:1841 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3857
Practice Address - Country:US
Practice Address - Phone:910-630-1112
Practice Address - Fax:910-425-1110
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2013-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00380407OtherMEDICARE RAILROAD
NC2768379Medicare PIN
Q77424Medicare UPIN