Provider Demographics
NPI:1568560761
Name:ERICSON, DAVID JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JOHN
Last Name:ERICSON
Suffix:
Gender:M
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 1:520 UPPER CHESAPEAKE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4360
Mailing Address - Country:US
Mailing Address - Phone:410-879-9100
Mailing Address - Fax:410-638-0408
Practice Address - Street 1:520 UPPER CHESAPEAKE DR STE 206
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014
Practice Address - Country:US
Practice Address - Phone:410-879-9100
Practice Address - Fax:410-638-0408
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057338363AM0700X
MDC0007193363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT435383Medicaid
MT000082549Medicare ID - Type UnspecifiedDAVID J. ERICSON, PA-C
MT435383Medicaid
PA394470Medicare PIN