Provider Demographics
NPI:1063889871
Name:ERICKSON, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8650 RIDGEWIND RD
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-4027
Mailing Address - Country:US
Mailing Address - Phone:952-513-7684
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-521-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCRNA 1826367500000X
MNR173107-7163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1063889871Medicaid
MN1063889871Medicaid