MEDICARE: SHANNON MARIE HACKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1003438037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MARIE HACKA

Provider Business Mailing Address
First Line	:	1680 WESTMINSTER ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-3039
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 MEADOWLANDS DR STE 1&2
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55127-2339
Country	:	US
Telephone Number	:	507-322-7752
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/13/2020

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Directions to “ SHANNON MARIE HACKA ” Practice Location

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