Provider Demographics
NPI:1649213091
Name:ERICKSON, LISA A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1702
Mailing Address - Country:US
Mailing Address - Phone:716-338-0033
Mailing Address - Fax:716-338-1575
Practice Address - Street 1:15 S MAIN ST
Practice Address - Street 2:SUITE 151
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6636
Practice Address - Country:US
Practice Address - Phone:716-483-0113
Practice Address - Fax:716-487-2893
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332351363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400168875OtherMEDICARE PTAN
NY2654231Medicaid
NYJ400168875OtherMEDICARE PTAN