Provider Demographics
NPI:1962803890
Name:ANKROM, EMILY M (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:M
Last Name:ANKROM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:M
Other - Last Name:HEITMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4340 CLYO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7000
Mailing Address - Country:US
Mailing Address - Phone:937-396-2602
Mailing Address - Fax:937-395-3682
Practice Address - Street 1:4340 CLYO RD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-7000
Practice Address - Country:US
Practice Address - Phone:937-534-7330
Practice Address - Fax:937-395-3682
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004088RX363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0342599Medicaid