Provider Demographics
NPI:1568451698
Name:HAKE, SHAWN CHRISTINE (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:CHRISTINE
Last Name:HAKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHANDALL
Other - Middle Name:CHRISTINE
Other - Last Name:GERASCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-4777
Mailing Address - Fax:414-805-4774
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-4777
Practice Address - Fax:414-805-4774
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42993700Medicaid
WIP11046Medicare UPIN