MEDICARE: LAURA E ERICKSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	9992	MN
2	363A00000X	Physician Assistant	5338	TN

General Provider Information

NPI Number	:	1114959814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA E ERICKSON PA-C

Provider Business Mailing Address
First Line	:	1193 FORT CAMPBELL BLVD. STE A
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37042
Country	:	US
Telephone Number	:	693-155-7302
Fax Number	:

Provider Business Practice Location Address
First Line	:	1193 FORT CAMPBELL BLVD. STE A
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37042
Country	:	US
Telephone Number	:	693-155-7302
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	02/20/2024

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