Provider Demographics
NPI:1245622646
Name:FERGEN, ERIC (PA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FERGEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 RAMAR RD STE 11
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7100
Mailing Address - Country:US
Mailing Address - Phone:928-704-9202
Mailing Address - Fax:928-704-9207
Practice Address - Street 1:1355 RAMAR RD STE 11
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7100
Practice Address - Country:US
Practice Address - Phone:928-704-9202
Practice Address - Fax:928-704-9207
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57093363A00000X, 363A00000X
AZ7075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1245622646Medicaid
NVV110064Medicare PIN