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General NPI Number Information
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NPI Number | 1780635748
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Entity Type | Individual
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Provider Name | AUTUMN RENAE ACKERMAN PA
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Gender | Female
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Dates
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Enumeration Date | 05/15/2006
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Last Update Date | 09/26/2012
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Provider Practice Location Address
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Address Line | 5656 S 129TH EAST AVE BUILDING C
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City | TULSA
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State | OK
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Zip | 74134-6715
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Country | US
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Telephone | 918-357-7378
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Fax | 918-357-7377
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Provider Business Mailing Address
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Address Line | 5656 S 129TH EAST AVE BUILDING C
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City | TULSA
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State | OK
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Zip | 74134-6715
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Country | US
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Telephone | 918-357-7378
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Fax | 918-357-7377
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1529
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License Number State | OK
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