Individual
MR. KEITH J HACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
1777 W GRAND AVE, PORT WASHINGTON, WI 53074-2077
(262) 284-3456
Mailing address
1777 W GRAND AVE, PORT WASHINGTON, WI 53074-2077
(262) 284-3456
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
523
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1952508400
—
WI
Enumeration date
06/28/2007
Last updated
11/23/2021
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