1003914391 NPI number — MRS. KELLY KATHLEEN ERICKSON PA-C

Table of content: MRS. KELLY KATHLEEN ERICKSON PA-C (NPI 1003914391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003914391 NPI number — MRS. KELLY KATHLEEN ERICKSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
KELLY
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLZER
Provider Other First Name:
KELLY
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003914391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
641 W WILLOUGHBY AVE
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
JUNEAU
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99801-1748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-586-8100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3245 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801-7809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-463-4040
Provider Business Practice Location Address Fax Number:
907-463-6663
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  666 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8EB370 . This is a "MEDICARE ID -TYPE UNSPECI" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 8ED920 . This is a "MEDICARE ID-TYPE UNSPECIF" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 8EB371 . This is a "MEDICARE ID -TYPE UNSPECI" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 8EB372 . This is a "MEDICARE ID-TYPE UNSPECIF" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 8EB373 . This is a "MEDICARE ID-TYPE UNSPECIF" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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