Provider Demographics
NPI:1053879361
Name:HANSEN, CAROL JEANNE
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEANNE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2092 PRASLIN ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-1025
Mailing Address - Country:US
Mailing Address - Phone:541-968-5958
Mailing Address - Fax:
Practice Address - Street 1:72A CENTENNIAL LOOP STE 150
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2447
Practice Address - Country:US
Practice Address - Phone:971-219-7949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000002476175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4854649OtherODOL