Basic Information
| Provider Information | |||||||||
| NPI: | 1932199981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E HAWAII AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633000 | ||||||||
| FaxNumber: | 2084633079 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E HAWAII AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633244 | ||||||||
| FaxNumber: | 2084633034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M5246 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 52464 | 01 | ID | BLUE CROSS | OTHER | 806359900 | 01 | ID | HEALTHY CONNECTIONS | OTHER | 002364400 | 05 | ID | MEDICAID | 080036990 | 01 | ID | RAILROAD MEDICARE | OTHER | 000010004475 | 01 | ID | BLUE SHIELD | OTHER |