Basic Information
| Provider Information | |||||||||
| NPI: | 1033446695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | KELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEAN | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | HOLMES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 393 COUNTRYSIDE DR | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922438403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173686666 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1415 ROSS AVE. /EL CENTRO REGIONAL MED.CTR. | ||||||||
| Address2: | C/O DR.MICHAEL K. BERRY M.D. | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603397100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2009 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA20643 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1033446695 | 05 | CA | MEDICAID |