Provider Demographics
NPI:1447467220
Name:HANSEN, JASON JOHN (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:JOHN
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 1:407 EAST 3RD STREET
Mailing Address - Street 2:ST. MARY'S MEDICAL CENTER
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-786-4357
Mailing Address - Fax:
Practice Address - Street 1:407 EAST 3RD STREET
Practice Address - Street 2:ST. MARY'S MEDICAL CENTER
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805
Practice Address - Country:US
Practice Address - Phone:218-786-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51714207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447467220Medicaid
MN1447467220Medicaid
MN1447467220Medicaid