Healthcare Provider Details

I. General information

NPI: 1407842057
Provider Name (Legal Business Name): CYNTHIA LYNN HANSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E BELTLINE AVE NE SUITE 101
GRAND RAPIDS MI
49525-4598
US

IV. Provider business mailing address

1525 E BELTLINE AVE NE SUITE 101
GRAND RAPIDS MI
49525-4598
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-0055
  • Fax: 616-363-5180
Mailing address:
  • Phone: 616-363-0055
  • Fax: 616-363-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002660
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: