Individual
ERICA M DEFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
2805 N KNOXVILLE AVE, PEORIA, IL 61604-2869
(309) 624-9400
(309) 624-2280
Mailing address
2805 N KNOXVILLE AVE, PEORIA, IL 61604-2869
(309) 624-9400
(309) 624-2280
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
085003126
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
37-1221637
TAX ID
—
01
—
776530
MEDICARE GROUP PIN
IL
01
—
809840
MEDICARE GROUP PTAN
IL
Enumeration date
12/27/2007
Last updated
10/02/2009
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