Provider Demographics
NPI:1124183892
Name:ACKERMAN, PETER JOSEPH (RN)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 JAY ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1455
Mailing Address - Country:US
Mailing Address - Phone:218-525-1920
Mailing Address - Fax:
Practice Address - Street 1:4209 JAY ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-1455
Practice Address - Country:US
Practice Address - Phone:218-525-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 114481-3163WG0000X
WI163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice