Provider Demographics
NPI:1083821441
Name:HAUCK, KRISTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:HAUCK
Suffix:
Gender:F
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5693 YMCA PARK DR W
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3280
Practice Address - Country:US
Practice Address - Phone:260-469-6603
Practice Address - Fax:260-486-6123
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000759A363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ48953Medicare UPIN
IN069860114Medicare PIN
INM4000040236Medicare PIN