Provider Demographics
NPI:1811987076
Name:PROCTOR, ERIN L (PA-C)
Entity type:Individual
Prefix:MISS
First Name:ERIN
Middle Name:L
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:315 E. ELM STE. 100
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4858
Practice Address - Country:US
Practice Address - Phone:208-459-7415
Practice Address - Fax:208-453-3307
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2013-01-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA 515363A00000X
IDPA-515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807034000Medicaid
ID807034000Medicaid