Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RP1001X | Pulmonary Disease | MD458117 | PA |
NPI | 1003115395 |
---|---|
Provider Name | Dr. Jason Thomas Ackrivo |
First Address | Philadelphia, PA 19104-4230 |
Second Address | Philadelphia, PA 19104-4230 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/03/2011 |
Last Update Date | 05/11/2018 |