Healthcare Provider Details

I. General information

NPI: 1558962191
Provider Name (Legal Business Name): ERIN L DOUGHERTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD STE 2E99
NEWARK DE
19718-2200
US

IV. Provider business mailing address

4755 OGLETOWN STANTON RD FL 3
NEWARK DE
19718-2200
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-5982
  • Fax: 302-733-6081
Mailing address:
  • Phone: 302-733-3475
  • Fax: 302-325-7056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA105199
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0011458
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: