Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | R3097 | TX |
N | 207Q00000X | Family Doctor | BP10053131 | TX |
N | 207Q00000X | Family Doctor | R3097 | TX |
NPI | 1609257971 |
---|---|
Provider Name | Malinda Hansen |
First Address | Fort Worth, TX 76107-2553 |
Second Address | Fort Worth, TX 76107-2553 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2015 |
Last Update Date | 20/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7100619250 | (05) | KY |