Provider Demographics
NPI:1811931397
Name:ERICSON, MARY MELINDA (PA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MELINDA
Last Name:ERICSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:MELINDA
Other - Last Name:KIMBERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3721 E US 412 HWY STE B
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-3018
Mailing Address - Country:US
Mailing Address - Phone:479-215-3080
Mailing Address - Fax:479-549-4059
Practice Address - Street 1:3721 E US 412 HWY STE B
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3018
Practice Address - Country:US
Practice Address - Phone:479-215-3080
Practice Address - Fax:479-549-4059
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-220363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G610P307Medicare PIN