Provider Demographics
NPI:1457531121
Name:HANWACKER, SCOTT (PA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:HANWACKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PROFESSIONAL VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-7904
Mailing Address - Country:US
Mailing Address - Phone:732-720-2555
Mailing Address - Fax:732-720-2556
Practice Address - Street 1:301 PROFESSIONAL VIEW DR
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-7904
Practice Address - Country:US
Practice Address - Phone:732-720-2555
Practice Address - Fax:732-720-2556
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009211363AS0400X
NY009211-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical