Active NPI 1164692950 Individual Practitioner Female Practitioner

Erin Monica Nulf , PA-C

Physician Assistant • Spokane Valley, WA

✓ Accepts Medicare Assignment

Professional Overview & Biography Verified Profile Summary

Erin Nulf, PA-C is a certified Physician Assistant practicing in Spokane Valley, WA. With approximately 20 years of clinical experience since graduating from University Of Texas Southwestern Medical School At Dallas in 2006, Erin Nulf delivers high-quality medical care to the local community at 1807 N HUTCHINSON RD.

Erin Nulf is affiliated with Mountain West Derm - Blackhart Pllc and accepts Medicare assignment.

Frequently performed procedures and clinical services include destruction of precancer skin growth, 2-14 growths, established patient outpatient office visit, destruction of skin growth. Full Medicare procedure pricing transparency rates and service volume details are listed on this profile.

Practice Location & Contact Primary Location

Practice Address

1807 N Hutchinson Rd

Spokane Valley, WA 992122444

Telephone 5094567414

Fax 5096240763

Associated Practice Facility / Clinic

🏢 Advanced Dermatology And Skin Surgery, Pllc Facility NPI 1710952882

Medicare Profile & Education

Medical School

University Of Texas Southwestern Medical School At Dallas

Graduation Year

2006

Medicare Assignment

✓ Accepts Assignment

Telehealth Flag

In-Person Only

Specialty Benchmarks & Practice Insights

Comparative analytics for Physician Assistant in Spokane Valley, WA

Senior Veteran Specialist (>20 Yrs)

Practitioner Clinical Experience

20 Yrs +9.7 yrs vs City Avg

City Avg: 10.3 Yrs

State Avg: 12.1 Yrs

Regional Practice Density

64 Specialists

Practicing in Spokane Valley, WA (3774 Statewide)

Telehealth Adoption Rate

3.1% Regional Adoption

In-Person Office Visits Only

Medicare Pricing Discount

29.7% Avg Savings

Under CMS Medicare Fee Schedule vs Standard Submitted Charges

Clinical Seniority & Experience Comparison

Dr. Nulf (20 Years) 20 Yrs

Spokane Valley Specialty Average (10.3 Years) 10.3 Yrs

Performed Procedures & Service Volume

Top Medicare Part B procedures performed by this practitioner

CMS Official Data (2024)

Reporting Year:

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
17003 Destruction of precancer skin growth, 2-14 growths	781	175	$7.08	$5.77
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	445	290	$133.12	$108.19
99213 Established patient office or other outpatient visit, typically 15 minutes	417	306	$92.25	$77.46
17000 Destruction of skin growth	363	249	$70.15	$37.94
17110 Destruction of up to 14 skin growths	234	188	$118.72	$74.16
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	170	129	$127.57	$78.94
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	158	121	$142.82	$101.80
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	90	72	$127.82	$81.95
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	50	42	$140.29	$103.78
99204 New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more	40	40	$173.15	$141.43
11307 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm	32	27	$146.63	$107.56
11312 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm	26	23	$166.28	$130.96
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	25	25	$112.14	$94.39
11200 Removal of skin tag, 1-15 skin tags	21	21	$97.40	$49.23
11102 Tangential biopsy of single skin lesion	17	17	$106.46	$58.51
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	16	16	$118.52	$77.92
11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs	16	15	$102.92	$56.78
17111 Destruction of skin growth, 15 or more growths	15	13	$136.67	$103.44

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
17003 Destruction of precancer skin growth, 2-14 growths	871	209	$6.93	$5.90
99213 Established patient office or other outpatient visit, typically 15 minutes	449	316	$91.59	$77.56
17000 Destruction of skin growth	408	279	$68.94	$39.23
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	395	263	$129.32	$109.97
17110 Destruction of up to 14 skin growths	184	146	$117.36	$79.96
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	172	124	$141.22	$100.88
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	157	124	$125.87	$84.85
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	104	81	$127.07	$81.22
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	52	44	$141.80	$106.96
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	42	42	$114.44	$96.32
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	35	32	$124.69	$68.98
11312 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm	26	25	$161.25	$137.48
11307 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm	26	22	$143.68	$113.08
17262 Destruction of cancer skin growth of trunk, arms, or legs, 1.1-2.0 cm	23	19	$183.66	$146.27
11102 Tangential biopsy of single skin lesion	22	22	$104.89	$69.12
11200 Removal of skin tag, 1-15 skin tags	21	20	$93.72	$51.40
99204 New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more	17	17	$173.03	$142.85
11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs	17	15	$105.06	$55.29
11900 Injection into skin growth, 1-7 growths	12	12	$58.45	$35.33

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
17003 Destruction of precancer skin growth, 2-14 growths	909	196	$7.17	$5.90
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	381	271	$131.71	$109.30
17000 Destruction of skin growth	380	279	$69.33	$37.71
99213 Established patient office or other outpatient visit, typically 15 minutes	376	287	$92.87	$77.24
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	196	140	$143.90	$95.25
17110 Destruction of up to 14 skin growths	171	148	$118.13	$75.20
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	146	119	$128.55	$79.01
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	87	75	$144.23	$108.04
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	77	61	$128.34	$74.28
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	66	66	$115.19	$95.36
11312 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm	59	49	$163.61	$127.02
99204 New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more	41	41	$171.72	$142.72
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	36	34	$122.08	$75.42
11307 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm	35	31	$149.40	$109.19
11200 Removal of skin tag, 1-15 skin tags	26	24	$92.75	$51.06
99212 Established patient office or other outpatient visit with straightforward medical decision making, if using time, 10 minutes or more	26	25	$57.29	$48.31
11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs	22	19	$106.56	$61.29
11900 Injection into skin growth, 1-7 growths	19	16	$60.23	$36.23
17262 Destruction of cancer skin growth of trunk, arms, or legs, 1.1-2.0 cm	18	17	$183.64	$150.47
11102 Tangential biopsy of single skin lesion	11	11	$106.23	$56.97

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	589	385	$130.05	$112.15
17003 Destruction of precancer skin growth, 2-14 growths	546	145	$7.00	$5.77
17000 Destruction of skin growth	275	222	$68.00	$37.58
17110 Destruction of up to 14 skin growths	172	146	$117.01	$79.72
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	168	119	$145.51	$98.42
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	160	122	$130.47	$84.76
99213 Established patient office or other outpatient visit, typically 15 minutes	149	121	$95.26	$78.53
99204 New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more	114	114	$170.92	$144.04
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	77	62	$130.00	$81.30
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	67	57	$147.00	$109.90
11312 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm	31	26	$165.00	$134.46
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	30	29	$125.00	$73.60
11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs	26	24	$107.00	$59.86
11307 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm	22	17	$150.00	$107.85
11200 Removal of skin tag, 1-15 skin tags	21	20	$92.10	$50.72
J7308 Aminolevulinic acid hcl for topical administration, 20%, single unit dosage form (354 mg)	19	16	$349.21	$338.35
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	19	19	$115.00	$96.92
96573 Application of light by qualified health care professional to destroy precancer skin growth	18	16	$245.00	$209.58
11102 Tangential biopsy of single skin lesion	17	15	$108.00	$67.75
11104 Punch biopsy, first skin growth	16	14	$135.00	$111.58

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
17003 Destruction of precancer skin growth, 2-14 growths	381	103	$7.00	$5.24
99213 Established patient office or other outpatient visit, typically 15 minutes	327	195	$77.42	$63.73
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	312	271	$112.07	$92.92
17000 Destruction of skin growth	189	157	$70.00	$38.40
17110 Destruction of up to 14 skin growths	132	109	$115.00	$77.15
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	123	97	$131.14	$80.93
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	82	64	$145.00	$105.65
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	62	44	$127.32	$77.96
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	49	49	$111.00	$92.42
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	47	40	$150.00	$109.25
99202 New patient office or other outpatient visit, typically 20 minutes	46	46	$79.13	$64.98
11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs	29	24	$103.17	$55.64
11104 Punch biopsy, first skin growth	26	23	$129.31	$105.06
J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg	25	17	$5.00	$1.48
11307 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm	21	17	$155.00	$119.23
11200 Removal of skin tag, 1-15 skin tags	17	16	$95.00	$54.32
11900 Injection into skin growth, 1-7 growths	16	14	$56.00	$35.89
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	15	13	$120.00	$63.66
17262 Destruction of cancer skin growth of trunk, arms, or legs, 1.1-2.0 cm	15	14	$181.53	$138.00
87220 Tissue fungi or parasites	14	12	$16.00	$4.26
11105 Punch biopsy, each additional skin growth	14	11	$63.00	$52.52
11102 Tangential biopsy of single skin lesion	11	11	$102.91	$67.46

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
17003 Destruction of precancer skin growth, 2-14 growths	865	180	$7.05	$4.86
99213 Established patient office or other outpatient visit, typically 15 minutes	482	296	$76.30	$63.69
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	331	291	$112.82	$92.87
17000 Destruction of skin growth	293	246	$70.96	$37.38
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	226	156	$127.43	$73.56
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	189	131	$146.35	$92.25
17110 Destruction of up to 14 skin growths	156	128	$115.87	$77.58
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	96	96	$111.72	$92.41
99202 New patient office or other outpatient visit, typically 20 minutes	96	96	$78.54	$65.71
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	82	66	$126.00	$83.09
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	58	50	$151.55	$107.10
J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg	53	27	$5.00	$1.58
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	52	45	$120.00	$65.62
11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs	40	36	$103.45	$55.20
11104 Punch biopsy, first skin growth	27	27	$128.00	$101.84
11312 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm	25	22	$172.08	$129.95
11307 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm	23	21	$155.00	$122.42
11200 Removal of skin tag, 1-15 skin tags	23	18	$111.52	$53.41
11901 Injection into skin growth, more than 7 growths	22	14	$71.00	$58.12
11900 Injection into skin growth, 1-7 growths	21	16	$56.00	$41.47
11102 Tangential biopsy of single skin lesion	19	19	$102.00	$58.70
87220 Tissue fungi or parasites	14	12	$16.00	$4.65
17262 Destruction of cancer skin growth of trunk, arms, or legs, 1.1-2.0 cm	12	11	$190.08	$137.89

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
17003 Destruction of precancer skin growth, 2-14 growths	595	134	$7.05	$4.45
99213 Established patient office or other outpatient visit, typically 15 minutes	472	285	$75.49	$61.98
17000 Destruction of skin growth	242	198	$70.83	$39.60
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	197	178	$111.42	$90.88
17110 Destruction of up to 14 skin growths	181	135	$120.80	$84.88
99202 New patient office or other outpatient visit, typically 20 minutes	148	148	$81.66	$63.81
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	116	116	$110.60	$91.56
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	106	81	$115.66	$67.48
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	101	75	$127.76	$80.11
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	64	56	$119.13	$79.43
11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs	46	39	$101.00	$56.93
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	45	37	$129.51	$89.20
11100 Biopsy of single growth of skin and/or tissue	43	41	$108.35	$78.06
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	42	38	$152.36	$103.67
J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg	35	19	$5.00	$1.80
99212 Established patient office or other outpatient visit with straightforward medical decision making, if using time, 10 minutes or more	26	25	$48.00	$37.54
11900 Injection into skin growth, 1-7 growths	25	17	$58.00	$39.61
11200 Removal of skin tag, 1-15 skin tags	20	17	$92.95	$50.06
11312 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm	18	18	$166.00	$138.41
11307 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm	16	13	$150.00	$109.22
11305 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less	12	12	$102.75	$53.37

HCPCS Code & Description	Services	Patients	Submitted Charge	Medicare Allowed
17003 Destruction of precancer skin growth, 2-14 growths	544	109	$7.04	$4.75
99213 Established patient office or other outpatient visit, typically 15 minutes	333	206	$80.69	$61.31
17000 Destruction of skin growth	216	180	$74.43	$42.51
17110 Destruction of up to 14 skin growths	137	117	$126.18	$87.41
99202 New patient office or other outpatient visit, typically 20 minutes	104	104	$81.47	$62.78
99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	84	77	$116.82	$90.72
99203 New patient office or other outpatient visit with low level of medical decision making, if using time, 30 minutes or more	79	79	$117.75	$90.14
11311 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 0.6-1.0 cm	41	38	$114.63	$74.43
11100 Biopsy of single growth of skin and/or tissue	20	20	$107.00	$83.32
11301 Shaving of skin growth of body, arms, or legs, 0.6-1.0 cm	20	19	$130.40	$91.24
11200 Removal of skin tag, 1-15 skin tags	17	16	$93.71	$55.22
11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth	16	16	$117.00	$88.03
11306 Shaving of skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm	16	15	$125.00	$97.90
11312 Shaving of skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm	14	14	$164.00	$136.75
99212 Established patient office or other outpatient visit with straightforward medical decision making, if using time, 10 minutes or more	12	12	$48.00	$36.88
11302 Shaving of skin growth of body, arms, or legs, 1.1-2.0 cm	11	11	$145.00	$115.21

Medical Specialties & State Licenses

CMS Verified: 2025-04-04

Physician Assistant Primary Specialty

NUCC Taxonomy Code: 363A00000X

State License WA PA60440358

A physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and is practicing within the scope of that license. Physician assistants are formally trained to perform many of the routine, time-consuming tasks a physician can do. In some states, they may prescribe medications. They take medical histories, perform physical exams, order lab tests and x-rays, and give inoculations. Most states require that they work under the supervision of a physician.

Physician Assistant

NUCC Taxonomy Code: 363A00000X

State License ID 6271157

Hospital & Practice Group Affiliations

Mountain West Derm - Blackhart Pllc

5905 N Mayfair St, Spokane, WA 992081127

Phone: 51293039091255

Mountain West Derm - Blackhart Pllc

3010 S Southeast Blvd, Spokane, WA 992233541

Phone: 5094567414

Secondary Practice Locations

5905 N Mayfair St

Spokane, WA 992081127

Phone: 5094567414

1700 W Riverstone Dr

Coeur D Alene, ID 838145683

Phone: 2087702822

3010 S Southeast Blvd Ste B

Spokane, WA 992233541

Phone: 5094567414

Practice Associates & Co-Workers

Healthcare professionals and specialists practicing at this location or sharing practice phone/fax

17 Associated Practitioners

Dr. James Parker , MD

Dermatology

NPI 1144789405

Doctor of Medicine (M.D.)

Elizabeth Jacobsen , PA-C

Physician Assistant - Medical

NPI 1154408631

Physician Assistant (Certified)

Taylor Morten , FNP-C

Nurse Practitioner

NPI 1184596777

Family Nurse Practitioner (Certified)

Dr. Joel Sears , MD

Dermatology - Procedural Dermatology

NPI 1184699365

Doctor of Medicine (M.D.)

Dr. Staci Hestdalen , MD

Dermatology

NPI 1194790006

Doctor of Medicine (M.D.)

Dr. Andrea Dominey , MD

Dermatology

NPI 1215023007

Doctor of Medicine (M.D.)

Career & Practice History Timeline

Chronological log of verified NPI updates, location relocations, credentials, and registry changes

9 Historical Events

📍

Updated Practice Location April 04, 2025

Registered at 1807 N HUTCHINSON RD, SPOKANE VALLEY, WA 992122444 (Tel: 5094567414)

📍

Updated Business Mailing Address April 04, 2025

Registered at 1807 N HUTCHINSON RD, SPOKANE VALLEY, WA 992122444 (Tel: 0954567414)

🎓

Medical Taxonomy / Specialty Registered (Primary Specialty) April 04, 2025

Physician Assistant (License #6271157 in ID)

✅

NPI Profile Active October 21, 2016

NPI status registered as active in NPPES database

📍

Updated Practice Location October 21, 2016

Registered at 757 E HOLLAND AVE, SPOKANE, WA 992181257 (Tel: 5094446371)

📍

Updated Business Mailing Address October 21, 2016

Registered at 757 E HOLLAND AVE, SPOKANE, WA 992181257 (Tel: 5094446367)

👤

Provider Name / Credentials Updated October 21, 2016

Recorded as ERIN NULF, PA-C

🎓

Medical Taxonomy / Specialty Registered (Primary Specialty) October 21, 2016

Physician Assistant (License #PA60440358 in WA)

🟢

Initial NPI Registration & Enumeration March 07, 2008

First registered as active Individual Practitioner in NPPES Database.

Patient & Community Reviews

Verified patient ratings, medical care experiences, and facility photos

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NPI Administrative Meta

NPI Number: 1164692950

Entity Type:

Individual Provider Physician, Nurse Practitioner, or Solo Healthcare Professional (Type 1 NPI)

Enumeration Date: March 07, 2008

Last Update: April 04, 2025

Sole Proprietor: No

Update or Correct Profile

Mailing Address

1807 N Hutchinson Rd

Spokane Valley, WA 992122444

Phone: 0954567414

Public Domain Record This profile contains public domain information published by CMS and NPPES under the Freedom of Information Act (FOIA).

⚠️ Medical Disclaimer

This directory listing is for informational purposes only and does not constitute medical advice, diagnosis, or physician endorsement. If you are experiencing a medical emergency, please call 911 immediately.