Healthcare Provider Details

I. General information

NPI: 1073659611
Provider Name (Legal Business Name): TATYANA ERDMANN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12075 E STATE ROUTE 69 STE B
DEWEY AZ
86327-4569
US

IV. Provider business mailing address

12075 E STATE ROUTE 69 STE B
DEWEY AZ
86327-4569
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-1673
  • Fax: 928-772-1674
Mailing address:
  • Phone: 928-772-1673
  • Fax: 928-213-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6763
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: