Provider Demographics
NPI:1477741577
Name:HAACK, TRACY L (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:HAACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:NONN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1211 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1909
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-288-6495
Practice Address - Street 1:1211 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1909
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-288-6495
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2204-23363A00000X
WI2204-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1477741577Medicaid
WI60750OtherDEAN HEALTH INSURANCE
WI102774150Medicare PIN
WI014257085Medicare PIN