Provider Demographics
NPI:1568194710
Name:HASSE, BETHANY (APRN)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:HASSE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3055 HUBERTUS RD
Practice Address - Street 2:
Practice Address - City:HUBERTUS
Practice Address - State:WI
Practice Address - Zip Code:53033-9316
Practice Address - Country:US
Practice Address - Phone:262-628-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13099363L00000X, 363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100226875Medicaid