MEDICARE: MR. JOHN HAUCK PA-C

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1598979114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN HAUCK PA-C

Provider Business Mailing Address
First Line	:	PO BOX 431
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-0431
Country	:	US
Telephone Number	:	253-651-0824
Fax Number	:

Provider Business Practice Location Address
First Line	:	4430 PO VALLEY ROAD
Second Line	:
City	:	FT DRUM
State	:	NY
Zip	:	13602-5134
Country	:	US
Telephone Number	:	315-772-1061
Fax Number	:

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	10/16/2009

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