Provider Demographics
NPI:1902299860
Name:ELLICOTT, ERICA LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LEIGH
Last Name:ELLICOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:NE
Mailing Address - Zip Code:69033-3112
Mailing Address - Country:US
Mailing Address - Phone:308-883-0658
Mailing Address - Fax:
Practice Address - Street 1:801 W C ST
Practice Address - Street 2:
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3591
Practice Address - Country:US
Practice Address - Phone:308-777-2476
Practice Address - Fax:308-223-5752
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant