Healthcare Provider Details

I. General information

NPI: 1487614160
Provider Name (Legal Business Name): PETER ACKERMAN PA-C, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 RIVERVIEW DR
DANBURY CT
06810
US

IV. Provider business mailing address

2 RIVERVIEW DR
DANBURY CT
06810-6268
US

V. Phone/Fax

Practice location:
  • Phone: 203-797-1500
  • Fax: 203-791-0495
Mailing address:
  • Phone: 203-797-1500
  • Fax: 203-791-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberNO LICENSES YET
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002645
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: