Provider Demographics
NPI:1770565186
Name:MOUDRY, ERICKA ROSE (PA)
Entity type:Individual
Prefix:MRS
First Name:ERICKA
Middle Name:ROSE
Last Name:MOUDRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERICKA
Other - Middle Name:ROSE
Other - Last Name:MRACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:901 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2325
Mailing Address - Country:US
Mailing Address - Phone:563-382-2911
Mailing Address - Fax:563-382-4143
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-382-2911
Practice Address - Fax:563-382-4143
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-19
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001593363AM0700X, 363AS0400X
MN10935363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAQ25509Medicare UPIN