Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | 4183 | AZ |
NPI | 1396716262 |
---|---|
Provider Name | Brent Paul Hansen |
First Address | Glendale, AZ 85308-1372 |
Second Address | Glendale, AZ 85308-1372 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2006 |
Last Update Date | 04/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
937732 | (05) | AZ |