Healthcare Provider Details

I. General information

NPI: 1356367155
Provider Name (Legal Business Name): AVON I HANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AVON IONE CHILD

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 28216 BOX HOHENFELS
APO AE
09173-8216
US

IV. Provider business mailing address

UNIT 28216 BOX HOHENFELS
APO AE
09173-8216
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-3316
  • Fax:
Mailing address:
  • Phone: 314-590-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004255
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: