=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760924534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEEANN M ACKER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2016
-----------------------------------------------------
Last Update Date | 11/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14541 W INDIAN SCHOOL RD STE 600
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-9243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-535-5599
-----------------------------------------------------
Fax | 623-535-4696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14541 W INDIAN SCHOOL RD STE 600
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-9243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-535-5599
-----------------------------------------------------
Fax | 623-535-4696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 6571
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------