Provider Demographics
NPI:1033446695
Name:DEAN, ERIN KELLE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KELLE
Last Name:DEAN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:HOLMES
Other - Last Name:DEAN
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:393 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-8403
Mailing Address - Country:US
Mailing Address - Phone:817-368-6666
Mailing Address - Fax:
Practice Address - Street 1:1415 ROSS AVE. /EL CENTRO REGIONAL MED.CTR.
Practice Address - Street 2:C/O DR.MICHAEL K. BERRY M.D.
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4306
Practice Address - Country:US
Practice Address - Phone:760-339-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1033446695Medicaid
CACQ533ZMedicare PIN