Provider Demographics
NPI:1053067405
Name:STAFFORD, ERICK (PA-C)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9036 WEEPING CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-5373
Mailing Address - Country:US
Mailing Address - Phone:813-796-2200
Mailing Address - Fax:
Practice Address - Street 1:30 SANDSTONE CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2073
Practice Address - Country:US
Practice Address - Phone:731-240-1695
Practice Address - Fax:731-240-1694
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1191813363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical