Healthcare Provider Details

I. General information

NPI: 1194034710
Provider Name (Legal Business Name): PAUL ROBERT HANSEN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 JOHNSON LANE MARE ISLAND
VALLEJO CA
94592
US

IV. Provider business mailing address

6576 FRIARS RD APT. 105
SAN DIEGO CA
92108-1000
US

V. Phone/Fax

Practice location:
  • Phone: 804-754-6118
  • Fax:
Mailing address:
  • Phone: 804-754-6118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number63493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: