Healthcare Provider Details

I. General information

NPI: 1316488562
Provider Name (Legal Business Name): LUCAS HANSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 W BROADWAY FL 7
SALT LAKE CITY UT
84101-2060
US

IV. Provider business mailing address

PO BOX 24449
NEW YORK NY
10087-0589
US

V. Phone/Fax

Practice location:
  • Phone: 917-634-5311
  • Fax:
Mailing address:
  • Phone: 917-634-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number0102207175
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number14148924-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: