MEDICARE: CHANTELLE MARIE ERICKSON PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3026	CO
2	363A00000X	Physician Assistant	3026	CO

General Provider Information

NPI Number	:	1144533928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANTELLE MARIE ERICKSON PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	400 S COLORADO BLVD STE 530
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80246-1255
Country	:	US
Telephone Number	:	720-640-6266
Fax Number	:	720-643-5903

Provider Business Practice Location Address
First Line	:	400 S COLORADO BLVD STE 530
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80246-1255
Country	:	US
Telephone Number	:	720-640-6266
Fax Number	:	303-643-5903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2010
Last Update Date	:	12/16/2021

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