Basic Information
| Provider Information | |||||||||
| NPI: | 1053067405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | ERICK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9036 WEEPING CHERRY LN | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380165373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137962200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 SANDSTONE CIR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312401695 | ||||||||
| FaxNumber: | 7312401694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2022 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1191813 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 1191813 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.