Provider Demographics
NPI:1215974977
Name:HARDER, DANE JAE (CRNA)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:JAE
Last Name:HARDER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 CONNIE LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-4254
Mailing Address - Country:US
Mailing Address - Phone:715-298-9111
Mailing Address - Fax:
Practice Address - Street 1:3400 MINISTRY PKWY
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5220
Practice Address - Country:US
Practice Address - Phone:715-393-2652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73953363LA2100X
WI394367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43285000Medicaid
WIR40563Medicare UPIN
WI36045-0002Medicare ID - Type Unspecified
WI211790100Medicare PIN
WI43285000Medicaid