Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207ND0101X | MOHS-Micrographic Surgeon | 01029310A | IN |
N | 207ND0101X | MOHS-Micrographic Surgeon | 18628 | IA |
N | 207ND0900X | Dermatopathologist | 01029310A | IN |
N | 207NS0135X | Procedural Dermatology | 01029310A | IN |
Y | 207NS0135X | Procedural Dermatology | 18628 | IA |
NPI | 1295771244 |
---|---|
Provider Name | Carl William Hanke |
First Address | Indianapolis, IN 46260-2385 |
Second Address | Indianapolis, IN 46260-2385 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2006 |
Last Update Date | 12/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0735829 | (05) | IA |
10062850A | (05) | IN |
10702 | WELLMARK BCBS (01) | IA |
C24350 | (02) |