Healthcare Provider Details

I. General information

NPI: 1215342787
Provider Name (Legal Business Name): ERICA M DZIATKIEWICZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERICA M HICKS

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36500 AURORA DR
SUMMIT WI
53066-4899
US

IV. Provider business mailing address

36500 AURORA DR
SUMMIT WI
53066-4899
US

V. Phone/Fax

Practice location:
  • Phone: 262-434-1000
  • Fax:
Mailing address:
  • Phone: 262-434-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3321-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: