Basic Information
| Provider Information | |||||||||
| NPI: | 1740595354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EATON | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | ERICA | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 N TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706428413 | ||||||||
| FaxNumber: | 9706419017 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N IOWA ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706428413 | ||||||||
| FaxNumber: | 9706419017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | PA.0003011 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.