Provider Demographics
NPI:1861620262
Name:HANSEN, LANCE A (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:A
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 1:465 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1544
Mailing Address - Country:US
Mailing Address - Phone:208-847-4495
Mailing Address - Fax:208-847-4336
Practice Address - Street 1:465 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1544
Practice Address - Country:US
Practice Address - Phone:208-847-4495
Practice Address - Fax:208-847-4336
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
20001049Medicare Oscar/Certification