Healthcare Provider Details

I. General information

NPI: 1699166850
Provider Name (Legal Business Name): JARED LINCOLN HANSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE
SAN DIEGO CA
92134-7000
US

IV. Provider business mailing address

27876 TWILIGHT CT
MURRIETA CA
92563-5063
US

V. Phone/Fax

Practice location:
  • Phone: 435-770-8086
  • Fax:
Mailing address:
  • Phone: 435-770-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1102X
TaxonomyMilitary Outpatient Operational (Transportable) Component Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: