Provider Demographics
NPI:1679518609
Name:ACKERMAN, MARK (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:CRNA
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 821
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-0821
Mailing Address - Country:US
Mailing Address - Phone:785-628-8300
Mailing Address - Fax:785-623-4634
Practice Address - Street 1:2220 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2370
Practice Address - Country:US
Practice Address - Phone:785-628-8300
Practice Address - Fax:785-623-4634
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54083367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS057275OtherBCBS OF KANSAS
KS100246310BMedicaid
KS57275Medicare PIN