Provider Demographics
NPI:1073598355
Name:ERICKSON, MITCHELL D (PA)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:D
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23968 NORTH 83RD LANE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383
Mailing Address - Country:US
Mailing Address - Phone:623-935-9328
Mailing Address - Fax:
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2635
Practice Address - Country:US
Practice Address - Phone:623-882-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2438363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ758013Medicaid
AZAW1436OtherHEALTHNET
AZ3981220OtherEVERCARE
AZ453051001OtherGROUP HEALTH
AZ860373636OtherHUMANA
AZ3981220OtherEVERCARE
AZAW1436OtherHEALTHNET