Provider Demographics
NPI:1467781310
Name:MCCONNAUGHEY, ERICKA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:ERICKA
Middle Name:LYNN
Last Name:MCCONNAUGHEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERICKA
Other - Middle Name:LYNN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:STE 3000
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1280
Mailing Address - Country:US
Mailing Address - Phone:937-299-8242
Mailing Address - Fax:937-299-8245
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 3000
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1280
Practice Address - Country:US
Practice Address - Phone:937-299-8242
Practice Address - Fax:937-299-8245
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-003005363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA35261Medicare PIN