Healthcare Provider Details

I. General information

NPI: 1396336434
Provider Name (Legal Business Name): NOAH JACK HANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 N MILL ST
FERTILE MN
56540-4330
US

IV. Provider business mailing address

13562 435TH ST SW
FERTILE MN
56540-9102
US

V. Phone/Fax

Practice location:
  • Phone: 218-945-3220
  • Fax:
Mailing address:
  • Phone: 218-280-5781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6810
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: