=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669954475
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIKA VANELLE MARIN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2018
-----------------------------------------------------
Last Update Date | 06/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2680 ESCALADE WAY
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-306-4128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 RALEIGH CT
-----------------------------------------------------
City | COLUMBIA CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46725-7422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-941-0641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------