Provider Demographics
NPI:1821161696
Name:ACKER, TATJANA LARISSA (PA)
Entity Type:Individual
Prefix:MRS
First Name:TATJANA
Middle Name:LARISSA
Last Name:ACKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2705
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-2705
Mailing Address - Country:US
Mailing Address - Phone:256-801-6048
Mailing Address - Fax:256-801-6218
Practice Address - Street 1:9000 BAILEY COVE RD SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-4002
Practice Address - Country:US
Practice Address - Phone:256-428-4900
Practice Address - Fax:256-428-4912
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51151377OtherBCBS
AL163234Medicaid
AL51151378OtherBCBS
AL51151378OtherBCBS