Provider Demographics
NPI:1861433443
Name:HANSEN, THOMAS R (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:T
Other - Middle Name:RANDY
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5880 S HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-9447
Mailing Address - Country:US
Mailing Address - Phone:928-425-3246
Mailing Address - Fax:928-425-3859
Practice Address - Street 1:5880 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9447
Practice Address - Country:US
Practice Address - Phone:928-425-3246
Practice Address - Fax:928-425-3859
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1803601205208600000X
AZ18493208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ172537OtherMCPTAN
UT000063293Medicare PIN
UTE28371Medicare UPIN
UT006477020Medicare PIN
AZZ172537OtherMCPTAN