Provider Demographics
NPI:1487614160
Name:ACKERMAN, PETER (PA-C, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:PA-C, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6268
Mailing Address - Country:US
Mailing Address - Phone:203-797-1500
Mailing Address - Fax:203-791-0495
Practice Address - Street 1:2 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-797-1500
Practice Address - Fax:203-791-0495
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTNO LICENSES YET2255A2300X
CT002645363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT999608OtherNSCA CSCS CERT. NUMBER
CT089902436OtherNATABOC CERT. NUMBER