Provider Demographics
NPI:1114959814
Name:ERICKSON, LAURA E (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:E
Other - Last Name:FOUQUETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1193 FORT CAMPBELL BLVD. STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042
Mailing Address - Country:US
Mailing Address - Phone:693-155-7302
Mailing Address - Fax:
Practice Address - Street 1:1193 FORT CAMPBELL BLVD. STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042
Practice Address - Country:US
Practice Address - Phone:693-155-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9992363A00000X
TN5338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant