Healthcare Provider Details

I. General information

NPI: 1447364724
Provider Name (Legal Business Name): TIMOTHY D ERICKSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. TIMOTHY ROLLIN ERICKSON

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 06/18/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRESBYTERIAN RUST MEDICAL CENTER 2400 UNSER BLVD SE STE 19100
RIO RANCHO NM
87124-4740
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8777
  • Fax: 505-253-6580
Mailing address:
  • Phone: 505-823-8777
  • Fax: 505-253-6580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2006-0017
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: