Healthcare Provider Details

I. General information

NPI: 1417489345
Provider Name (Legal Business Name): HANSON MOUANOUTOUA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY # K303
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6900
  • Fax: 208-625-6910
Mailing address:
  • Phone: 208-625-6900
  • Fax: 208-625-6910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberO-1696
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: