Healthcare Provider Details

I. General information

NPI: 1003885617
Provider Name (Legal Business Name): DR. LOREN ERICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 UNIVERSITY AVE W SUITE 19-C
SAINT PAUL MN
55104-3898
US

IV. Provider business mailing address

1600 UNIVERSITY AVE W SUITE 19-C
SAINT PAUL MN
55104-3898
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-7084
  • Fax:
Mailing address:
  • Phone: 651-646-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number444
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number759
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number444
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number444
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number444
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number759
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number113462
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: