Healthcare Provider Details

I. General information

NPI: 1093289969
Provider Name (Legal Business Name): COURTNEY HANSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E SUPERIOR ST STE 306
CHICAGO IL
60611-2595
US

IV. Provider business mailing address

344 E CENTRAL AVE
LOMBARD IL
60148-3903
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 734-604-6341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006911
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: