Provider Demographics
NPI:1710375696
Name:HACKER, DREW THOMAS (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:THOMAS
Last Name:HACKER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1997
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1997
Mailing Address - Country:US
Mailing Address - Phone:414-604-7512
Mailing Address - Fax:414-604-7509
Practice Address - Street 1:3365 S 103RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4161
Practice Address - Country:US
Practice Address - Phone:414-604-7512
Practice Address - Fax:414-604-7509
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI919-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS
WI919-39OtherSTATE LICENSE