Healthcare Provider Details

I. General information

NPI: 1164622098
Provider Name (Legal Business Name): PRAIRIE DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 LAFAYETTE ST S
ABERDEEN SD
57401-5524
US

IV. Provider business mailing address

3 LAFAYETTE ST S
ABERDEEN SD
57401-5524
US

V. Phone/Fax

Practice location:
  • Phone: 605-226-0560
  • Fax: 605-226-1653
Mailing address:
  • Phone: 605-226-0560
  • Fax: 605-226-1653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number7021
License Number StateSD

VIII. Authorized Official

Name: DR. TY HANSON
Title or Position: DERMATOLOGIST
Credential: D.O.
Phone: 605-226-0560