1992357982 NPI number — LAUREN ANN ACKERMAN PA-C

Table of content: LAUREN ANN ACKERMAN PA-C (NPI 1992357982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992357982 NPI number — LAUREN ANN ACKERMAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ACKERMAN
Provider First Name:
LAUREN
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992357982
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
788 N JEFFERSON ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53202-3710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-272-8950
Provider Business Mailing Address Fax Number:
414-274-6250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 E RAMSEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUDAHY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53110-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-647-7170
Provider Business Practice Location Address Fax Number:
414-662-2507
Provider Enumeration Date:
07/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  4771-23 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1992357982 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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