Healthcare Provider Details

I. General information

NPI: 1881678738
Provider Name (Legal Business Name): DUWAYNE ALLEN HANSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1861 KNOLLWOOD DR
FAIRMONT MN
56031-2303
US

IV. Provider business mailing address

1861 KNOLLWOOD DR
FAIRMONT MN
56031-2303
US

V. Phone/Fax

Practice location:
  • Phone: 507-238-2985
  • Fax:
Mailing address:
  • Phone: 507-238-2985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20233
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: