Healthcare Provider Details

I. General information

NPI: 1861945743
Provider Name (Legal Business Name): BRENT HANSON MSN, CNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 1ST ST
DULUTH MN
55805-2407
US

IV. Provider business mailing address

1401 E 1ST ST
DULUTH MN
55805-2407
US

V. Phone/Fax

Practice location:
  • Phone: 218-728-4491
  • Fax: 218-730-2367
Mailing address:
  • Phone: 218-728-4491
  • Fax: 218-730-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR190864-8
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP4747
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: