Healthcare Provider Details

I. General information

NPI: 1437327475
Provider Name (Legal Business Name): GLENN A. HANSEN, D.P.M.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 S ONEIDA ST
GREEN BAY WI
54304-5267
US

IV. Provider business mailing address

2331 S ONEIDA ST
GREEN BAY WI
54304-5267
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-1177
  • Fax: 920-499-5398
Mailing address:
  • Phone: 920-499-1177
  • Fax: 920-499-5398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number403-025
License Number StateWI

VIII. Authorized Official

Name: DR. GLENN A. HANSEN
Title or Position: SOLE PROPRIETOR
Credential: D.P.M.
Phone: 920-499-1177