Basic Information
| Provider Information | |||||||||
| NPI: | 1710911516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | LERON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80217 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850600217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023852115 | ||||||||
| FaxNumber: | 4804183323 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 E BANNER GATEWAY DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809642908 | ||||||||
| FaxNumber: | 4808332136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 35613 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 35613 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5550830003 | 01 | AZ | MEDICARE NSC PEORIA | OTHER | 5550830006 | 01 | AZ | MEDICARE NSC ANTHEM | OTHER | 5550830007 | 01 | AZ | MEDICARE NSC DV | OTHER | 5550830010 | 01 | AZ | MEDICARE NSC GILBERT | OTHER | 5550830004 | 01 | AZ | MEDICARE NSC PV | OTHER | P00346251 | 01 | AZ | RR MEDICARE | OTHER | 112448 | 05 | AZ | MEDICAID | 5550830001 | 01 | AZ | MEDICARE NSC SCW | OTHER | 5550830008 | 01 | AZ | MEDICARE NSC SWV | OTHER | 5550830009 | 01 | AZ | MEDICARE NSC AZ NORTH | OTHER |