Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0131X | Foot Surgery | 403-025 | WI |
NPI | 1194732669 |
---|---|
Provider Name | Glenn A Hansen |
First Address | Green Bay, WI 54304-5267 |
Second Address | Green Bay, WI 54304-5267 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 26/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
43217500 | (05) | WI |
T62116 | (02) | WI |