Provider Demographics
NPI:1114232766
Name:ERICKSON, GREGORY S (MS, CRNA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:S
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MS, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 7TH ST N APT 11
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-3419
Mailing Address - Country:US
Mailing Address - Phone:612-998-1410
Mailing Address - Fax:
Practice Address - Street 1:1117 7TH ST N APT 11
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-3419
Practice Address - Country:US
Practice Address - Phone:612-998-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 100585-5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered