Healthcare Provider Details

I. General information

NPI: 1740275650
Provider Name (Legal Business Name): MARY HANSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PEARL ST STE 1400
BROCKTON MA
02301-2864
US

IV. Provider business mailing address

1 PEARL ST STE 1400
BROCKTON MA
02301-2864
US

V. Phone/Fax

Practice location:
  • Phone: 508-897-6030
  • Fax: 508-897-6015
Mailing address:
  • Phone: 508-897-6030
  • Fax: 508-897-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number206301
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: