Provider Demographics
NPI:1629037130
Name:HAACK, ANN M (PA)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:HAACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 CENTENNIAL HILLS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3265
Mailing Address - Country:US
Mailing Address - Phone:307-265-7205
Mailing Address - Fax:307-235-6262
Practice Address - Street 1:4140 CENTENNIAL HILLS BLVD
Practice Address - Street 2:STE A
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3265
Practice Address - Country:US
Practice Address - Phone:307-265-7205
Practice Address - Fax:307-235-6262
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313835OtherBCBS
WYW20512Medicare PIN
WY313835OtherBCBS
Q54759Medicare UPIN