Basic Information
| Provider Information | |||||||||
| NPI: | 1518954874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 731280 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753731280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188419532 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4600 AMBASSADOR CAFFERY PKWY | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372615151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 04/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 020858 | LA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1674095 | 05 | LA | MEDICAID | 220031201 | 01 | LA | RAILROAD MEDICARE | OTHER |