Basic Information
| Provider Information | |||||||||
| NPI: | 1831188127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HACK | ||||||||
| FirstName: | VICKI | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 SOUTH 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | OAKES | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584742024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017423267 | ||||||||
| FaxNumber: | 7017423201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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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 | 363AM0700X | PAC0233 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PAC0233 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 18954 | 01 | ND | BLUE SHIELD | OTHER | 28594 | 01 | ND | BLUE SHIELD | OTHER | 28596 | 01 | ND | BLUE SHIELD | OTHER | 970013748 | 01 | ND | RAILROAD MEDICARE | OTHER | 18955 | 01 | ND | BLUE SHIELD | OTHER | CF8850 | 01 | ND | RAILROAD MEDICARE | OTHER | 28595 | 01 | ND | BLUE SHIELD | OTHER | 71051 | 05 | ND | MEDICAID | 18953 | 01 | ND | BLUE SHIELD | OTHER | 25995 | 01 | ND | BLUE SHIELD | OTHER |