Provider Demographics
NPI:1124693288
Name:HANSEN, NATHANIAL WILLIAM (DO)
Entity type:Individual
Prefix:
First Name:NATHANIAL
Middle Name:WILLIAM
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 W 49TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3113
Mailing Address - Country:US
Mailing Address - Phone:801-450-8459
Mailing Address - Fax:
Practice Address - Street 1:1475 W 49TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3113
Practice Address - Country:US
Practice Address - Phone:801-450-8459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS22349390200000X
MI5151015061207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207N00000XAllopathic & Osteopathic PhysiciansDermatology