Healthcare Provider Details

I. General information

NPI: 1063089340
Provider Name (Legal Business Name): BRANDON D HANSON RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

2450 65TH AVE S APT 306
FARGO ND
58104-6792
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2000
  • Fax:
Mailing address:
  • Phone: 916-903-8382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberR-1332
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: