Provider Demographics
NPI:1093997355
Name:HANINGTON ERICKSON, KRISTIN ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:HANINGTON ERICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3304
Mailing Address - Country:US
Mailing Address - Phone:920-261-2020
Mailing Address - Fax:920-261-0457
Practice Address - Street 1:132 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098
Practice Address - Country:US
Practice Address - Phone:920-261-2020
Practice Address - Fax:920-261-0457
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3212-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3212-23OtherLICENSE NUMBER
WAG8890273Medicare UPIN