Healthcare Provider Details

I. General information

NPI: 1922626803
Provider Name (Legal Business Name): COLIN HANSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 HIGHWAY 528 NW STE 106A
ALBUQUERQUE NM
87114-7025
US

IV. Provider business mailing address

15 APEX DR
HIGHLAND IL
62249-1282
US

V. Phone/Fax

Practice location:
  • Phone: 505-800-7810
  • Fax: 505-800-7810
Mailing address:
  • Phone: 877-224-4354
  • Fax: 618-654-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5710
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: