1447364724 NPI number — MR. TIMOTHY D ERICKSON PA-C

Table of content: MR. TIMOTHY D ERICKSON PA-C (NPI 1447364724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447364724 NPI number — MR. TIMOTHY D ERICKSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
TIMOTHY
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ERICKSON
Provider Other First Name:
TIMOTHY
Provider Other Middle Name:
ROLLIN
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447364724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26666
Provider Second Line Business Mailing Address:
PHS PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-823-8777
Provider Business Mailing Address Fax Number:
505-253-6580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PRESBYTERIAN RUST MEDICAL CENTER
Provider Second Line Business Practice Location Address:
2400 UNSER BLVD SE STE 19100
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-4740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-823-8777
Provider Business Practice Location Address Fax Number:
505-253-6580
Provider Enumeration Date:
08/17/2006

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: 363A00000X , with the licence number:  PA2006-0017 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA2006-0017 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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