Provider Demographics
NPI:1124557301
Name:HACKER, ETHAN ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:ANDREW
Last Name:HACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CLAY EDWARDS DRIVE, MEDICAL STAFF SERVICES
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116
Mailing Address - Country:US
Mailing Address - Phone:816-691-1655
Mailing Address - Fax:
Practice Address - Street 1:2790 CLAY EDWARDS DR STE 520570
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3276
Practice Address - Country:US
Practice Address - Phone:816-221-6750
Practice Address - Fax:816-221-7280
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-09160207R00000X
OK35503207RC0000X
MO2025032202207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease