Healthcare Provider Details

I. General information

NPI: 1114966751
Provider Name (Legal Business Name): SUSAN JANELLE HANSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 GOLD DR
FARGO ND
58103-6413
US

IV. Provider business mailing address

4450 31ST AVE S STE 102
FARGO ND
58104-4557
US

V. Phone/Fax

Practice location:
  • Phone: 701-280-2033
  • Fax: 701-232-5578
Mailing address:
  • Phone: 701-280-2033
  • Fax: 701-232-5578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAC0312
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: