Provider Demographics
NPI:1396520045
Name:HAUCK, MATT
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:HAUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 N MAIN ST STE D162
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1401
Mailing Address - Country:US
Mailing Address - Phone:801-448-7385
Mailing Address - Fax:
Practice Address - Street 1:265 N MAIN ST STE D162
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1401
Practice Address - Country:US
Practice Address - Phone:801-448-7385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty