MEDICARE: MRS. ERICA AIMEE HANSEN PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	A2449	MN

General Provider Information

NPI Number	:	1467096123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ERICA AIMEE HANSEN PTA

Provider Business Mailing Address
First Line	:	2622 ULYSSES ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-3048
Country	:	US
Telephone Number	:	651-408-5669
Fax Number	:

Provider Business Practice Location Address
First Line	:	4461 WHITE BEAR PKWY STE 1
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-7626
Country	:	US
Telephone Number	:	651-645-4540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2019
Last Update Date	:	11/05/2019

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