Provider Demographics
NPI:1407832728
Name:HAACK, JASON P (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:HAACK
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 1:191 OVERTHRUST RD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9261
Mailing Address - Country:US
Mailing Address - Phone:307-789-8721
Mailing Address - Fax:307-789-8664
Practice Address - Street 1:191 OVERTHRUST RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9261
Practice Address - Country:US
Practice Address - Phone:307-789-8721
Practice Address - Fax:307-789-8664
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7953A207YX0905X, 207YX0905X
MN45725207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY06329001OtherBCBS WY
WY1407832728Medicaid
MN433920700Medicaid
MN040000711Medicare ID - Type Unspecified
WY1407832728Medicaid
WYW22075Medicare PIN