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General NPI Number Information
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NPI Number | 1720794498
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Entity Type | Individual
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Provider Name | GRANT HANSON
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Gender | Male
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Dates
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Enumeration Date | 01/26/2023
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Last Update Date | 08/08/2024
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Provider Practice Location Address
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Address Line | 18465 ORCHARD TRL STE 200
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City | LAKEVILLE
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State | MN
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Zip | 55044-2525
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Country | US
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Telephone | 651-468-7689
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Fax |
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Provider Business Mailing Address
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Address Line | 561 S ELK ST
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City | BELLE PLAINE
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State | MN
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Zip | 56011-1507
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 3792
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License Number State | MN
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