1104319110 NPI number — VICTORIA HANSON

Table of content: VICTORIA HANSON (NPI 1104319110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104319110 NPI number — VICTORIA HANSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANSON
Provider First Name:
VICTORIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104319110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18716 GARDNER RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97415-8214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-226-1386
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 COVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97415-2520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-469-0222
Provider Business Practice Location Address Fax Number:
541-469-0228
Provider Enumeration Date:
06/13/2018

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 680503 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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