Healthcare Provider Details

I. General information

NPI: 1962113548
Provider Name (Legal Business Name): KEVIN WADE-HANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10138 W PAYSON RD
TOLLESON AZ
85353-8441
US

IV. Provider business mailing address

10138 W PAYSON RD
TOLLESON AZ
85353-8441
US

V. Phone/Fax

Practice location:
  • Phone: 414-759-7445
  • Fax:
Mailing address:
  • Phone: 414-759-7445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberD06300831
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code246ZB0301X
TaxonomyBiomedical Engineer
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code246ZB0500X
TaxonomyBiochemist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: