Provider Demographics
NPI:1902944044
Name:ACKLEY, LEE T (RPA-C)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:T
Last Name:ACKLEY
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 331
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:NY
Mailing Address - Zip Code:12936-0331
Mailing Address - Country:US
Mailing Address - Phone:518-963-4275
Mailing Address - Fax:518-963-8862
Practice Address - Street 1:39 FARRELL ROAD
Practice Address - Street 2:
Practice Address - City:WILLSBORO
Practice Address - State:NY
Practice Address - Zip Code:12996
Practice Address - Country:US
Practice Address - Phone:518-963-4275
Practice Address - Fax:518-963-8862
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003464-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003464-1OtherPHYSICIAN ASSISTANT LICEN
NY003464-1OtherPHYSICIAN ASSISTANT LICEN
NY003464-1OtherPHYSICIAN ASSISTANT LICEN