Provider Demographics
NPI:1184637407
Name:ACKERMAN, REID (PA-C)
Entity Type:Individual
Prefix:
First Name:REID
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 FARMINGTON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2123
Mailing Address - Country:US
Mailing Address - Phone:505-325-2323
Mailing Address - Fax:
Practice Address - Street 1:2130 FARMINGTON AVE STE A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2123
Practice Address - Country:US
Practice Address - Phone:505-325-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0002363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical