Provider Demographics
NPI:1770766511
Name:HANINGTON ERICKSON, ANDREW CRAIG (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:CRAIG
Last Name:HANINGTON ERICKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDRE
Other - Middle Name:
Other - Last Name:HANINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 35TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1932
Mailing Address - Country:US
Mailing Address - Phone:262-652-3500
Mailing Address - Fax:
Practice Address - Street 1:1020 35TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-652-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-16
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3192363A00000X
OH50.002534363A00000X
WAPA10005354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770766511Medicaid
WI1770766511Medicaid