Doctor Name: | MRS. ERIN L MICENHEIMER |
NPI Number: | 1871897207 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PA-C |
License Number: | 085004262 |
Business Practice Address: | 1702 Vaughn Rd Wood River, IL - 620951898 |
Business Phone Number: | 6182593321 |
Business Fax Number: | |
Mailing Address: | 1702 Vaughn Rd, WOOD RIVER |
State: | IL |
Postal Code: | 620951898 |
Phone Number: | 6182593321 |
Fax Number: | |
NPI Enumeration Date: | 12/28/2010 |
NPI Last Update Date: | 04/12/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AM0700X |
License Number: | 085004262 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Medical |
Taxonomy Definition: |