Provider Demographics
NPI:1003914391
Name:ERICKSON, KELLY KATHLEEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:KATHLEEN
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:KATHLEEN
Other - Last Name:HOLZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:641 W WILLOUGHBY AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1748
Mailing Address - Country:US
Mailing Address - Phone:908-586-8100
Mailing Address - Fax:
Practice Address - Street 1:3245 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7809
Practice Address - Country:US
Practice Address - Phone:907-463-4040
Practice Address - Fax:907-463-6663
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK666363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK8EB370OtherMEDICARE ID -TYPE UNSPECI
AK8ED920OtherMEDICARE ID-TYPE UNSPECIF
AK8EB371OtherMEDICARE ID -TYPE UNSPECI
AK8EB372OtherMEDICARE ID-TYPE UNSPECIF
AK8EB373OtherMEDICARE ID-TYPE UNSPECIF
AK8EB371OtherMEDICARE ID -TYPE UNSPECI
AKQ07528Medicare UPIN