1205142924 NPI number — KEELY FITZGERALD HANSON PA-C

Table of content: KEELY FITZGERALD HANSON PA-C (NPI 1205142924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205142924 NPI number — KEELY FITZGERALD HANSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANSON
Provider First Name:
KEELY
Provider Middle Name:
FITZGERALD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FITZGERALD
Provider Other First Name:
KEELY
Provider Other Middle Name:
MAYRE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205142924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
476 WILLIAMS WAY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MOAB
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84532-2186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-259-7121
Provider Business Mailing Address Fax Number:
435-259-3112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476 WILLIAMS WAY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MOAB
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84532-2186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-259-7121
Provider Business Practice Location Address Fax Number:
435-259-3112
Provider Enumeration Date:
08/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  TL 1548 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8035121-1206 . This is a "UT MEDICAL LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 13520505 . This is a "CAQH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1205142924 . This is a "NPI" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: UT014851 . This is a "UT MEDICAL LIABILITY" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 8035121-8906 . This is a "UT CONTROLLED SUBSTANCE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: U000088825 . This is a "PTAN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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