Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 18626 | MN |
NPI | 1184642589 |
---|---|
Provider Name | Carlton R Erickson |
First Address | Wyoming, MN 55092-8013 |
Second Address | Wyoming, MN 55092-8013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 16/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D75659 | (02) | MN |