Provider Demographics
NPI:1457706665
Name:JAGUN, ERICA O (AA-S)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:O
Last Name:JAGUN
Suffix:
Gender:F
Credentials:AA-S
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:BAMGBOPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 305
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3660
Mailing Address - Country:US
Mailing Address - Phone:414-649-6000
Mailing Address - Fax:
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-649-6000
Practice Address - Fax:414-649-5296
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132-017367H00000X, 367H00000X
MO2016017429367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100086698Medicaid