Provider Demographics
NPI:1588615306
Name:HAECKER, DANIEL WALTER (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WALTER
Last Name:HAECKER
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Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:3030 N CIRCLE DR
Mailing Address - Street 2:STE 210
Mailing Address - City:COLORADO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1180
Mailing Address - Country:US
Mailing Address - Phone:719-228-9440
Mailing Address - Fax:719-228-9061
Practice Address - Street 1:2955 PROFESSIONAL PL
Practice Address - Street 2:SUITE 201
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-8139
Practice Address - Country:US
Practice Address - Phone:719-591-5545
Practice Address - Fax:719-591-5540
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-02-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO594363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08581886Medicaid
CO08581886Medicaid