Provider Demographics
NPI:1679788152
Name:HANSEN, RUSSELL (RD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 MILES AVE
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-4530
Mailing Address - Country:US
Mailing Address - Phone:406-656-6139
Mailing Address - Fax:406-656-0253
Practice Address - Street 1:2945 MILES AVE
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-4530
Practice Address - Country:US
Practice Address - Phone:406-656-6139
Practice Address - Fax:406-656-0253
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT221133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered