Provider Demographics
NPI:1659864940
Name:ERICKSON, KRISTIN RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:RENEE
Last Name:ERICKSON
Suffix:
Gender:F
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 1:620 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-2234
Mailing Address - Country:US
Mailing Address - Phone:920-597-0030
Mailing Address - Fax:
Practice Address - Street 1:5409 VERN HOLMES DR
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482-8853
Practice Address - Country:US
Practice Address - Phone:715-342-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4376-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant