Provider Demographics
NPI:1326357070
Name:HACKENBERG, AMBER ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ANN
Last Name:HACKENBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:ANN
Other - Last Name:JANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-6000
Mailing Address - Fax:208-302-6055
Practice Address - Street 1:323 E RIVERSIDE DRIVE
Practice Address - Street 2:STE 224
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-302-6000
Practice Address - Fax:208-302-6055
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA152970363A00000X
IDPA-948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant