Basic Information
| Provider Information | |||||||||
| NPI: | 1124251715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GWINN | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | BETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404411949 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 6015 AYERS RD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457109492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554465937 | ||||||||
| FaxNumber: | 7406981905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2009 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.10901 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 128650 | 05 | OH | MEDICAID |