Provider Demographics
NPI:1356752257
Name:ACKERMAN, ELYSSA (MD)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12127B HWY 14 N STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9557
Mailing Address - Country:US
Mailing Address - Phone:505-814-1995
Mailing Address - Fax:
Practice Address - Street 1:3420 CONSTITUTION AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1238
Practice Address - Country:US
Practice Address - Phone:505-738-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2017-1023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine