Healthcare Provider Details

I. General information

NPI: 1114232766
Provider Name (Legal Business Name): GREGORY S. ERICKSON MS, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 7TH ST N APT 11
SAINT CLOUD MN
56303-3419
US

IV. Provider business mailing address

1117 7TH ST N APT 11
SAINT CLOUD MN
56303-3419
US

V. Phone/Fax

Practice location:
  • Phone: 612-998-1410
  • Fax:
Mailing address:
  • Phone: 612-998-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 100585-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: