Provider Demographics
NPI:1386491082
Name:HAERTNER, MICAH (NP)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:HAERTNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 E STEGALL RD
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:TX
Mailing Address - Zip Code:76706-5409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HILLCREST MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8897
Practice Address - Country:US
Practice Address - Phone:254-202-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX856192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner