Healthcare Provider Details

I. General information

NPI: 1891150108
Provider Name (Legal Business Name): ERICA LANKENAU PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W MAPLE ST
FARMINGTON NM
87401-6113
US

IV. Provider business mailing address

PO BOX 6210
FARMINGTON NM
87499-6210
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6300
  • Fax: 505-609-6301
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1130229
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2015-0082
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: