Healthcare Provider Details

I. General information

NPI: 1831464130
Provider Name (Legal Business Name): SHAUN B HANSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD STE 102
SAINT LOUIS MO
63128
US

IV. Provider business mailing address

10012 KENNERLY RD STE 102
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-6066
  • Fax:
Mailing address:
  • Phone: 314-849-6066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC10011397
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2019020900
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: