1467644757 NPI number — SAMUEL VAUGHAN HANSON WILLIS M.D.

Table of content: SAMUEL VAUGHAN HANSON WILLIS M.D. (NPI 1467644757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467644757 NPI number — SAMUEL VAUGHAN HANSON WILLIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANSON WILLIS
Provider First Name:
SAMUEL
Provider Middle Name:
VAUGHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIS
Provider Other First Name:
SAMUEL
Provider Other Middle Name:
VAUGHAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467644757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2155 FORD PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55116-1862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-696-5000
Provider Business Mailing Address Fax Number:
651-696-5001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 FORD PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55116-1862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-696-5000
Provider Business Practice Location Address Fax Number:
651-696-5001
Provider Enumeration Date:
08/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  49888 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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