Provider Demographics
NPI:1881637023
Name:HACKSHAW, CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:HACKSHAW
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 1:3843 GLEBE RD
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8251
Mailing Address - Country:US
Mailing Address - Phone:707-295-6080
Mailing Address - Fax:
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-262-5050
Practice Address - Fax:707-262-5053
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51195207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C511950Medicaid
CA00C511950Medicaid
CA00C511952Medicare PIN