Healthcare Provider Details

I. General information

NPI: 1790739092
Provider Name (Legal Business Name): RONALD WAYNE HANSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6636 CEDAR AVE S STE 170
RICHFIELD MN
55423-2710
US

IV. Provider business mailing address

6636 CEDAR AVE S STE 170
RICHFIELD MN
55423-2710
US

V. Phone/Fax

Practice location:
  • Phone: 612-800-5096
  • Fax: 877-511-7874
Mailing address:
  • Phone: 612-800-5096
  • Fax: 877-511-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number48888
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number49997
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: