Provider Demographics
NPI:1003454786
Name:IKETANI, ERICA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNN
Last Name:IKETANI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:LYNN
Other - Last Name:SHEEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2114 SW 102ND TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3254
Mailing Address - Country:US
Mailing Address - Phone:321-987-9095
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD RM 10-504
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant