Healthcare Provider Details

I. General information

NPI: 1699361568
Provider Name (Legal Business Name): DEVIN K HANSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 W EMERALD ST
BOISE ID
83704-8613
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3900
  • Fax: 208-302-3955
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1962
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: