Basic Information
| Provider Information | |||||||||
| NPI: | 1770041691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | GENOVA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W 52ND ST | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145355 | ||||||||
| FaxNumber: | 9036145399 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 DYKE THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755012104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032765404 | ||||||||
| FaxNumber: | 9033347256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2019 | ||||||||
| LastUpdateDate: | 03/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP136038 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | AP136038 | 01 | TX | APRN LICENSE NUMBER | OTHER | 803397 | 01 | TX | RN LICENSE NUMBER | OTHER | F11170086 | 01 | AANP FNP CERTIFICATION NUMBER | OTHER |