Provider Demographics
NPI:1104590710
Name:MUMFORD, ERICA MARIE (PA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIE
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 HORIZON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7808
Mailing Address - Country:US
Mailing Address - Phone:972-475-8914
Mailing Address - Fax:
Practice Address - Street 1:3136 HORIZON RD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7808
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:214-764-0880
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA15175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program