Provider Demographics
NPI:1740610377
Name:HACK, DANIEL ROGER (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROGER
Last Name:HACK
Suffix:
Gender:M
Credentials:PA-C
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 746654
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6654
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-393-7603
Practice Address - Street 1:1301 PALM AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8432
Practice Address - Country:US
Practice Address - Phone:904-202-7300
Practice Address - Fax:904-202-7433
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL9115794363A00000X
NY017058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant