Provider Demographics
NPI:1871897207
Name:MICENHEIMER, ERIN L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:L
Last Name:MICENHEIMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ERIN
Other - Middle Name:L
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1702 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1898
Mailing Address - Country:US
Mailing Address - Phone:618-259-3321
Mailing Address - Fax:
Practice Address - Street 1:1702 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1898
Practice Address - Country:US
Practice Address - Phone:618-259-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004262363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical