Basic Information
Provider Information | |||||||||
NPI: | 1003914391 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERICKSON | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | KATHLEEN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOLZER | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | KATHLEEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 641 W WILLOUGHBY AVE | ||||||||
Address2: | STE 201 | ||||||||
City: | JUNEAU | ||||||||
State: | AK | ||||||||
PostalCode: | 998011748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9085868100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3245 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | JUNEAU | ||||||||
State: | AK | ||||||||
PostalCode: | 998017809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074634040 | ||||||||
FaxNumber: | 9074636663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 02/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 666 | AK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 8EB370 | 01 | AK | MEDICARE ID -TYPE UNSPECI | OTHER | 8ED920 | 01 | AK | MEDICARE ID-TYPE UNSPECIF | OTHER | 8EB371 | 01 | AK | MEDICARE ID -TYPE UNSPECI | OTHER | 8EB372 | 01 | AK | MEDICARE ID-TYPE UNSPECIF | OTHER | 8EB373 | 01 | AK | MEDICARE ID-TYPE UNSPECIF | OTHER |