Basic Information
| Provider Information | |||||||||
| NPI: | 1427462910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HACKER | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | ARNP, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3192 BROWN LOOP | ||||||||
| Address2: | |||||||||
| City: | DUPONT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983278790 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | ATTN: CREDENTIALS OFFICE | ||||||||
| Address2: | 9040 JACKSON AVE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2014 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP9252618 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 012757000 | 05 | FL | MEDICAID |