Healthcare Provider Details

I. General information

NPI: 1427092592
Provider Name (Legal Business Name): TIMOTHY EARL HANSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

IV. Provider business mailing address

3860 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-1010
  • Fax: 505-796-9051
Mailing address:
  • Phone: 505-828-1010
  • Fax: 505-796-9051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA-964-99
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA-964-99
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: