Provider Demographics
NPI:1588757736
Name:ERVIN, JOHN ALLEN III (PAC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALLEN
Last Name:ERVIN
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-353-6360
Mailing Address - Fax:319-353-7006
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-353-6360
Practice Address - Fax:319-353-7006
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001392363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA27884OtherWELLMARK BCBS
IAI1421024Medicare PIN
IA27884OtherWELLMARK BCBS
IAI18607Medicare ID - Type Unspecified