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NPI Code Detail

MEDICARE: AUTUMN RENAE ACKERMAN PA

MEDICARE: AUTUMN RENAE ACKERMAN PA
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
1363AM0700XMedical Physician Assistant1529OK

General Provider Information

NPI Number : 1780635748
Entity Type Code : Individual
Provider Name (Legal Business Name) : AUTUMN RENAE ACKERMAN PA
Provider Business Mailing Address
First Line : 5656 S 129TH EAST AVE
Second Line : BUILDING C
City : TULSA
State : OK
Zip : 74134-6715
Country : US
Telephone Number : 918-357-7378
Fax Number : 918-357-7377
Provider Business Practice Location Address
First Line : 5656 S 129TH EAST AVE
Second Line : BUILDING C
City : TULSA
State : OK
Zip : 74134-6715
Country : US
Telephone Number : 918-357-7378
Fax Number : 918-357-7377
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/15/2006
Last Update Date : 09/26/2012

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Directions to “ AUTUMN RENAE ACKERMAN PA” Practice Location

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