Healthcare Provider Details

I. General information

NPI: 1326164526
Provider Name (Legal Business Name): HANSEN-STULTS SURGICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 W 1325 N 350
CEDAR CITY UT
84721-7792
US

IV. Provider business mailing address

166 W 1325 N SUITE 350
CEDAR CITY UT
84721-7792
US

V. Phone/Fax

Practice location:
  • Phone: 435-586-8192
  • Fax: 435-586-7564
Mailing address:
  • Phone: 435-586-8192
  • Fax: 435-586-7564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number3586141205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier529966761002
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: DR. MARK T HANSEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 435-586-8192