Provider Demographics
NPI:1679633655
Name:HACKER, BRANT NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:NICHOLAS
Last Name:HACKER
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 1:900 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MN
Mailing Address - Zip Code:56256-1006
Mailing Address - Country:US
Mailing Address - Phone:320-598-7551
Mailing Address - Fax:320-598-3798
Practice Address - Street 1:900 2ND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MN
Practice Address - Zip Code:56256-1006
Practice Address - Country:US
Practice Address - Phone:320-598-7551
Practice Address - Fax:320-598-3798
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN508995600Medicaid
MN080014080Medicare ID - Type Unspecified
MN508995600Medicaid