Healthcare Provider Details

I. General information

NPI: 1780677195
Provider Name (Legal Business Name): SETH ROBERT HANSEN MS, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FORT AVE
KEYSER WV
26726-2600
US

IV. Provider business mailing address

96 LONGVIEW LN
OAKLAND MD
21550-6929
US

V. Phone/Fax

Practice location:
  • Phone: 304-788-6880
  • Fax: 304-788-6871
Mailing address:
  • Phone: 301-387-2691
  • Fax: 304-788-6871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: