Provider Demographics
NPI:1407833742
Name:ERICKSON, KATE T (PAC)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:T
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:T
Other - Last Name:SCHEFFLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:5803 NEAL AVE N
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2177
Mailing Address - Country:US
Mailing Address - Phone:651-439-8807
Mailing Address - Fax:651-439-0232
Practice Address - Street 1:5803 NEAL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-2177
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9913363A00000X
WI3228-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q31094Medicare UPIN
MN313675200Medicaid
Q31094Medicare UPIN