Healthcare Provider Details

I. General information

NPI: 1033446695
Provider Name (Legal Business Name): ERIN KELLE DEAN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN HOLMES DEAN JR.

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 ROSS AVE. /EL CENTRO REGIONAL MED.CTR. C/O DR.MICHAEL K. BERRY M.D.
EL CENTRO CA
92243-4306
US

IV. Provider business mailing address

393 COUNTRYSIDE DR
EL CENTRO CA
92243-8403
US

V. Phone/Fax

Practice location:
  • Phone: 760-339-7100
  • Fax:
Mailing address:
  • Phone: 817-368-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: