Healthcare Provider Details

I. General information

NPI: 1558303669
Provider Name (Legal Business Name): DAVID K. HANSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 W MEDICAL CENTER DR SUITE A201
MCHENRY IL
60050-8419
US

IV. Provider business mailing address

4309 W MEDICAL CENTER DR SUITE A201
MCHENRY IL
60050-8419
US

V. Phone/Fax

Practice location:
  • Phone: 815-385-0084
  • Fax: 815-385-8968
Mailing address:
  • Phone: 815-385-0084
  • Fax: 815-385-8968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-000385
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: