Healthcare Provider Details

I. General information

NPI: 1619047339
Provider Name (Legal Business Name): MIRIAM L HANSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12319 N MOPAC EXPY BLDG. C, STE. 100
AUSTIN TX
78758-2403
US

IV. Provider business mailing address

12319 N MOPAC EXPY BLDG. C, STE. 100
AUSTIN TX
78758-2403
US

V. Phone/Fax

Practice location:
  • Phone: 512-837-3376
  • Fax: 512-837-3377
Mailing address:
  • Phone: 512-837-3376
  • Fax: 512-837-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM6174
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: