Provider Demographics
NPI:1689217911
Name:HANSON, DAVID JEFFREY (PAC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JEFFREY
Last Name:HANSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 GRAND CENTRAL BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4148
Mailing Address - Country:US
Mailing Address - Phone:912-748-1515
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:105 GRAND CENTRAL BLVD STE 108
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4148
Practice Address - Country:US
Practice Address - Phone:912-748-1515
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1806363A00000X, 363AM0700X
GA12647363AM0700X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12647OtherGA MEDCAL BOARD PA LICENSE
IDPA1806OtherLICENSE