Healthcare Provider Details

I. General information

NPI: 1588757736
Provider Name (Legal Business Name): JOHN ALLEN ERVIN III PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4841 SE 14TH ST
DES MOINES IA
50320-1616
US

IV. Provider business mailing address

PO BOX 746870
ATLANTA GA
30374-6870
US

V. Phone/Fax

Practice location:
  • Phone: 515-415-4081
  • Fax: 515-506-5085
Mailing address:
  • Phone: 833-804-1695
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001392
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001392
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: