Provider Demographics
NPI:1336233055
Name:ERICKSON, KARA (PAC)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:ERICKSON
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 1:2600 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5094
Mailing Address - Country:US
Mailing Address - Phone:406-233-2600
Mailing Address - Fax:406-233-2553
Practice Address - Street 1:2600 WILSON STREET
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5016
Practice Address - Country:US
Practice Address - Phone:406-233-2600
Practice Address - Fax:406-233-2763
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0437427Medicaid
MT261OtherMT STATELIC NUMBER
MT0437427OtherBCBS PROVIDER NUMBER
MT0437427Medicaid
MT261OtherMT STATELIC NUMBER