Prairie Roots Wellness, LLC

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Legal business name

PRAIRIE ROOTS WELLNESS, LLC

Practice address

801 W C St
MC Cook, NE 69001-3591

Phone

(308) 777-2476

Fax

(308) 223-5752

NPI assigned

Feb 12, 2024

Last updated

Feb 12, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Erica Ellicott, PA-CNPI 1902299860

Title

Physician Assistant

Phone

(308) 883-0658

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in NE

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Erica Leigh Ellicott, PA-C

  • Physician Assistant
  • McCook, NE
  • NPI 1902299860
  Medicare reassignment Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1707696000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707696000000",
    "number": "1467216275",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 565",
            "city": "MC COOK",
            "state": "NE",
            "postal_code": "690010565",
            "telephone_number": "308-777-2476",
            "fax_number": "308-223-5752"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "801 W C ST",
            "city": "MC COOK",
            "state": "NE",
            "postal_code": "690013591",
            "telephone_number": "308-777-2476",
            "fax_number": "308-223-5752"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRAIRIE ROOTS WELLNESS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-02-12",
        "last_updated": "2024-02-12",
        "certification_date": "2024-02-12",
        "status": "A",
        "authorized_official_last_name": "ELLICOTT",
        "authorized_official_first_name": "ERICA",
        "authorized_official_title_or_position": "PHYSICIAN ASSISTANT",
        "authorized_official_telephone_number": "308-883-0658",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH ID",
            "identifier": "13552224",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10027548401",
            "state": "NE"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDIVIDUAL NPI",
            "identifier": "1902299860",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Stacey Porter
• Tandi Porter
• Samantha Post, MOT, OTR/L
• David J Powell, PA-C
• Brittany Powers
• Ana Renee Priest
• Havin Proud
• Quality Urgent Care
• Michelle Pruneda Raburn, CSW
• Jaimee Radel

• Physician Assistant in McCook, NE
• Providers in McCook, NE by specialty
• Physician Assistant in Nebraska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.