Healthcare Provider Details

I. General information

NPI: 1114013208
Provider Name (Legal Business Name): MARK M HANSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 ADAMS AVE STE B
MORTON WA
98356-9323
US

IV. Provider business mailing address

PO BOX 1138
MORTON WA
98356-0019
US

V. Phone/Fax

Practice location:
  • Phone: 360-496-5145
  • Fax: 360-496-5093
Mailing address:
  • Phone: 360-496-5145
  • Fax: 360-496-5093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberP35289
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: