Provider Demographics
NPI:1366530354
Name:ERICKSEN, LISA M (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ERICKSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:318 WAVERLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1339
Mailing Address - Country:US
Mailing Address - Phone:124-822-9149
Mailing Address - Fax:
Practice Address - Street 1:29200 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2228
Practice Address - Country:US
Practice Address - Phone:734-523-2420
Practice Address - Fax:734-523-2464
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001522363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP11512Medicare UPIN