MEDICARE: MR. LEE EDWARD ACKLEY PA-C, MPAS, RT(R)

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA02732	TX

General Provider Information

NPI Number	:	1417933813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEE EDWARD ACKLEY PA-C, MPAS, RT(R)

Provider Business Mailing Address
First Line	:	901 INDIANA AVE
Second Line	:	STE 540
City	:	WICHITA FALLS
State	:	TX
Zip	:	76301-6734
Country	:	US
Telephone Number	:	940-696-0011
Fax Number	:	940-696-2248

Provider Business Practice Location Address
First Line	:	4412 KELL BLVD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76309-4719
Country	:	US
Telephone Number	:	940-696-0011
Fax Number	:	940-696-2248

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	09/24/2021

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