Healthcare Provider Details

I. General information

NPI: 1215271267
Provider Name (Legal Business Name): ERSAN EROL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4208 CENTRAL AVE SW STE G
ALBUQUERQUE NM
87105-1695
US

IV. Provider business mailing address

PO BOX 740018
ATLANTA GA
30374-0018
US

V. Phone/Fax

Practice location:
  • Phone: 505-777-3001
  • Fax:
Mailing address:
  • Phone: 608-324-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106966
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85008357
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5180
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2024-0077
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: