Provider Demographics
NPI:1780635748
Name:ACKERMAN, AUTUMN RENAE (PA)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:RENAE
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:RENAE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5656 S 129TH EAST AVE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-6715
Mailing Address - Country:US
Mailing Address - Phone:918-357-7378
Mailing Address - Fax:918-357-7377
Practice Address - Street 1:5656 S 129TH EAST AVE
Practice Address - Street 2:BUILDING C
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-6715
Practice Address - Country:US
Practice Address - Phone:918-357-7378
Practice Address - Fax:918-357-7377
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1529363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK242623302Medicare PIN