Healthcare Provider Details

I. General information

NPI: 1689217911
Provider Name (Legal Business Name): DAVID JEFFREY HANSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 GRAND CENTRAL BLVD STE 108
POOLER GA
31322-4148
US

IV. Provider business mailing address

105 GRAND CENTRAL BLVD STE 108
POOLER GA
31322-4148
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-1515
  • Fax: 844-807-3782
Mailing address:
  • Phone: 912-748-1515
  • Fax: 208-625-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1806
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1806
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12647
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: