MEDICARE: TIMOTHY EMIL HANSEN A.T.C.

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	2255A2300X	Athletic Trainer	AT000734	GA

General Provider Information

NPI Number	:	1740241520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY EMIL HANSEN A.T.C.

Provider Business Mailing Address
First Line	:	1109 PLEASANT OAKS CT
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-7603
Country	:	US
Telephone Number	:	404-894-2529
Fax Number	:	404-894-0695

Provider Business Practice Location Address
First Line	:	150 BOBBY DODD WAY NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30332-0001
Country	:	US
Telephone Number	:	404-894-2529
Fax Number	:

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

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	07/08/2007

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