Provider Demographics
NPI:1306020334
Name:DEFORD, ERICA M (PA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:M
Last Name:DEFORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:M
Other - Last Name:PLATTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2805 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-624-9400
Mailing Address - Fax:309-624-2280
Practice Address - Street 1:2805 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-624-9400
Practice Address - Fax:309-624-2280
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003126363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP PTAN
IL776530OtherMEDICARE GROUP PIN
37-1221637OtherTAX ID
37-1221637OtherTAX ID
IL809840OtherMEDICARE GROUP PTAN