Provider Demographics
NPI:1053810846
Name:WAGNER, ERICA BOHLKE (PA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:BOHLKE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:MARIE
Other - Last Name:BOHLKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3305 CENTRAL PARK VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-7707
Mailing Address - Country:US
Mailing Address - Phone:651-406-8860
Mailing Address - Fax:
Practice Address - Street 1:3305 CENTRAL PARK VILLAGE DR STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-7707
Practice Address - Country:US
Practice Address - Phone:651-406-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12588363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical