Provider Demographics
NPI:1447364724
Name:ERICKSON, TIMOTHY D (PA-C)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:D
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:TIMOTHY
Other - Middle Name:ROLLIN
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-823-8777
Mailing Address - Fax:505-253-6580
Practice Address - Street 1:PRESBYTERIAN RUST MEDICAL CENTER
Practice Address - Street 2:2400 UNSER BLVD SE STE 19100
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4740
Practice Address - Country:US
Practice Address - Phone:505-823-8777
Practice Address - Fax:505-253-6580
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2006-0017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPA2006-0017OtherMEDICAL LICENSE
NMPA2006-0017OtherMEDICAL LICENSE