Provider Demographics
NPI:1467927657
Name:ERICKSON, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1934
Mailing Address - Country:US
Mailing Address - Phone:507-247-5521
Mailing Address - Fax:507-537-9053
Practice Address - Street 1:240 WILLOW ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-1201
Practice Address - Country:US
Practice Address - Phone:507-247-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7183363LF0000X
SDCP001466363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1467927657Medicaid