Provider Demographics
NPI:1972169340
Name:ERICSON, CODY (NP)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:
Last Name:ERICSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 W CAMBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-4124
Mailing Address - Country:US
Mailing Address - Phone:707-337-1023
Mailing Address - Fax:
Practice Address - Street 1:400 W MINERAL KING AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6237
Practice Address - Country:US
Practice Address - Phone:559-624-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95009597OtherBOARD OF REGISTERED NURSING (BRN)