Provider Demographics
NPI:1780657080
Name:DOHERTY, ERIN M (PAC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:M
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 EVERGREEN DR
Mailing Address - Street 2:SUITE 20
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1032
Mailing Address - Country:US
Mailing Address - Phone:484-785-3376
Mailing Address - Fax:610-358-6913
Practice Address - Street 1:500 EVERGREEN DR
Practice Address - Street 2:SUITE 20
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1032
Practice Address - Country:US
Practice Address - Phone:484-785-3376
Practice Address - Fax:610-358-6913
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P98646Medicare UPIN
PA073508Medicare ID - Type Unspecified