Provider Demographics
NPI:1134135130
Name:HAECKER, NATHAN R (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:R
Last Name:HAECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17645 WRIGHT ST STE 300
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17645 WRIGHT ST STE 300
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2195
Practice Address - Country:US
Practice Address - Phone:833-667-2967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86994207Q00000X
TXS5639207Q00000X
NY304100207Q00000X
WI742-320207Q00000X
SD11947207Q00000X
NC2020-00796207Q00000X
MN66988207Q00000X
COCDR.0000656207Q00000X
IL036.152227207Q00000X
OH35.138831207Q00000X
PAMD471166207Q00000X
MIEMC0000218207Q00000X
IN01083698A207Q00000X
KY54014207Q00000X
NE23926207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025121400Medicaid