MEDICARE: NICHOLAS GARY HANSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	84392901205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10161981	OTHER		PHYSICIANS DOB

General Provider Information

NPI Number	:	1710149794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS GARY HANSON M.D.

Provider Business Mailing Address
First Line	:	24 S 1100 E STE 310
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1500
Country	:	US
Telephone Number	:	801-328-1260
Fax Number	:	801-350-4361

Provider Business Practice Location Address
First Line	:	24 S 1100 E STE 310
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84102-1500
Country	:	US
Telephone Number	:	801-328-1260
Fax Number	:	801-350-4361

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	01/12/2021

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