Healthcare Provider Details

I. General information

NPI: 1053887067
Provider Name (Legal Business Name): CHASE K HANSEN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E BRICKYARD RD APT 1803
SALT LAKE CITY UT
84106-2531
US

IV. Provider business mailing address

1121 E BRICKYARD RD APT 1803
SALT LAKE CITY UT
84106-2531
US

V. Phone/Fax

Practice location:
  • Phone: 801-309-0848
  • Fax:
Mailing address:
  • Phone: 801-309-0848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number10787299-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: