Provider Demographics
NPI:1154686020
Name:ERICKSON, BRONWEN KAYE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:BRONWEN
Middle Name:KAYE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:BRONWEN
Other - Middle Name:KAYE
Other - Last Name:WEICHERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:675 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9659
Mailing Address - Country:US
Mailing Address - Phone:541-214-2598
Mailing Address - Fax:458-202-7040
Practice Address - Street 1:2921 DOCTORS PARK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8127
Practice Address - Country:US
Practice Address - Phone:541-973-2551
Practice Address - Fax:541-973-2835
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201350053NP363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500669209Medicaid