1578093407 NPI number — MR. TAYLOR G HANSON MA 60645888

Table of content: MR. TAYLOR G HANSON MA 60645888 (NPI 1578093407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578093407 NPI number — MR. TAYLOR G HANSON MA 60645888

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANSON
Provider First Name:
TAYLOR
Provider Middle Name:
G
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA 60645888
Provider Gender Code:
M

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:
1578093407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
719 N HOMESTEAD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99019-7508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-294-6662
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16201 E INDIANA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99216-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-294-6662
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2017

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: 225700000X , with the licence number:  60645888 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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