Provider Demographics
NPI:1184848897
Name:ERICKSON, KENNETH WAYNE (FNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W H ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-3557
Mailing Address - Country:US
Mailing Address - Phone:209-848-4180
Mailing Address - Fax:209-848-5337
Practice Address - Street 1:1420 W H ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3557
Practice Address - Country:US
Practice Address - Phone:209-848-4180
Practice Address - Fax:209-848-5337
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP14456OtherCALIFORNIA NP CERTIFICATE