Provider Demographics
NPI:1124557301
Name:HACKER, ETHAN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:ANDREW
Last Name:HACKER
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 1:3901 RAINBOW BLVD # MS 2027
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8500
Mailing Address - Country:US
Mailing Address - Phone:913-588-3974
Mailing Address - Fax:913-588-6055
Practice Address - Street 1:800 STANTON L YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5018
Practice Address - Country:US
Practice Address - Phone:405-271-4742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-09160207R00000X
OK35503207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine