Provider Demographics
NPI:1861591836
Name:HACKER, MARK (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HACKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WEST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:220-564-4151
Mailing Address - Fax:220-564-7153
Practice Address - Street 1:1320 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:220-564-4151
Practice Address - Fax:220-564-7153
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002469RX363A00000X
CA53306363AM0700X
OH50.002469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical