Provider Demographics
NPI:1376776898
Name:ERICKSON, EMILY R (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:R
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4925
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4925
Mailing Address - Country:US
Mailing Address - Phone:515-247-3211
Mailing Address - Fax:515-643-8933
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2613
Practice Address - Country:US
Practice Address - Phone:515-247-3211
Practice Address - Fax:515-643-8933
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002028363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA440670046Medicare PIN