Provider Demographics
NPI:1023368206
Name:BAUER, ERIN LEAH (PA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:LEAH
Last Name:BAUER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:LEAH
Other - Last Name:KINGSBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7950 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 2121
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-435-7937
Mailing Address - Fax:260-435-7933
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7937
Practice Address - Fax:260-435-7933
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001434A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN692190001Medicare PIN