Healthcare Provider Details

I. General information

NPI: 1467517011
Provider Name (Legal Business Name): CHAD JEROME HANSON MSPT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 9TH AVE NW
WATERTOWN SD
57201-1548
US

IV. Provider business mailing address

PO BOX 1210
WATERTOWN SD
57201-6210
US

V. Phone/Fax

Practice location:
  • Phone: 605-882-7000
  • Fax:
Mailing address:
  • Phone: 605-882-7000
  • Fax: 605-882-7819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0046
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1039
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: