Provider Demographics
NPI:1265872790
Name:SUTTON, ERICA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:NICOLE
Last Name:SUTTON
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 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:1540 E. GROVE STREET
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-2736
Practice Address - Country:US
Practice Address - Phone:217-893-7700
Practice Address - Fax:217-893-7801
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085004712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400095771Medicare UPIN