Healthcare Provider Details

I. General information

NPI: 1689303802
Provider Name (Legal Business Name): SOPHIA LYNN HANSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15245 BLUEBIRD ST NW
ANDOVER MN
55304-3538
US

IV. Provider business mailing address

8366 FAIRCHILD AVE
SAINT PAUL MN
55112-6121
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-4688
  • Fax:
Mailing address:
  • Phone: 763-248-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14727
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: