Provider Demographics
NPI:1710093612
Name:ACKERMAN, MARK FREDERICK (PAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FREDERICK
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-9029
Mailing Address - Country:US
Mailing Address - Phone:208-476-4555
Mailing Address - Fax:208-476-5385
Practice Address - Street 1:1055 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9029
Practice Address - Country:US
Practice Address - Phone:208-476-4555
Practice Address - Fax:208-476-5385
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-392363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant