Healthcare Provider Details

I. General information

NPI: 1275723157
Provider Name (Legal Business Name): KEVIN ERDMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25320 75TH ST
SALEM WI
53168-9684
US

IV. Provider business mailing address

25320 75TH ST
SALEM WI
53168-9684
US

V. Phone/Fax

Practice location:
  • Phone: 262-843-2336
  • Fax:
Mailing address:
  • Phone: 262-843-2336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1161-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1161-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: