=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992193924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA HANSEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2014
-----------------------------------------------------
Last Update Date | 12/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2275 DEMING WAY
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53562-5527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-417-8366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2275 DEMING WAY
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53562-5527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-417-8366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1168
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------