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General NPI Number Information
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NPI Number | 1497403760
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Entity Type | Organization
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Legal Business Name | MAX HANSEN SURGERY PLLC
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Dates
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Enumeration Date | 03/15/2022
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Last Update Date | 03/15/2022
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Provider Practice Location Address
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Address Line | 381 E 4TH N STE 100
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City | REXBURG
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State | ID
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Zip | 83440-1684
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Country | US
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Telephone | 208-656-8442
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Fax | 208-656-8453
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Provider Business Mailing Address
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Address Line | PO BOX 185
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City | REXBURG
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State | ID
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Zip | 83440-0185
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Country | US
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Telephone | 208-656-8442
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Fax | 208-656-8453
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Authorized Official
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Title or Position | DOCTOR OF OSTEOPATH - SURGEON
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Name | DWAYNE MAXWELL HANSEN JR.
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Credential | DO
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Telephone | 208-656-8442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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