Provider Demographics
NPI:1902582430
Name:MERCADO, ERICA (PA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:MERCADO
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 1:1700 KEYSTONE PACIFIC PKWY UNIT B
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363-8874
Mailing Address - Country:US
Mailing Address - Phone:209-892-9100
Mailing Address - Fax:209-892-9102
Practice Address - Street 1:1700 KEYSTONE PACIFIC PKWY UNIT B
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:CA
Practice Address - Zip Code:95363-8874
Practice Address - Country:US
Practice Address - Phone:209-892-9100
Practice Address - Fax:209-892-9102
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA63608363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2446SIV0Medicaid