Healthcare Provider Details

I. General information

NPI: 1619244704
Provider Name (Legal Business Name): HANS JEFFREY HULSEBOS M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N TENAYA WAY 480
LAS VEGAS NV
89128-0443
US

IV. Provider business mailing address

9436 DEER LODGE LN
LAS VEGAS NV
89129-6961
US

V. Phone/Fax

Practice location:
  • Phone: 401-862-4597
  • Fax:
Mailing address:
  • Phone: 401-862-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number46768
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: