Healthcare Provider Details

I. General information

NPI: 1790191542
Provider Name (Legal Business Name): BRENT HANSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 FRANCE AVE S STE 400
EDINA MN
55435-2137
US

IV. Provider business mailing address

6565 FRANCE AVE S STE 400
EDINA MN
55435-2137
US

V. Phone/Fax

Practice location:
  • Phone: 952-225-1630
  • Fax:
Mailing address:
  • Phone: 952-225-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number25MA10284000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number68991
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: