Healthcare Provider Details

I. General information

NPI: 1124557301
Provider Name (Legal Business Name): ETHAN ANDREW HACKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 08/22/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 CLAY EDWARDS DR STE 520570
NORTH KANSAS CITY MO
64116-3276
US

IV. Provider business mailing address

2800 CLAY EDWARDS DRIVE, MEDICAL STAFF SERVICES
NORTH KANSAS CITY MO
64116
US

V. Phone/Fax

Practice location:
  • Phone: 816-221-6750
  • Fax: 816-221-7280
Mailing address:
  • Phone: 816-691-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number94-09160
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35503
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number2025032202
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: