Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MD00042707 | WA |
Y | 207QS0010X | Family Doctor - Sports Medicine | MD00042707 | WA |
NPI | 1295703221 |
---|---|
Provider Name | Michael Shane Erickson |
First Address | Salt Lake City, UT 84125-0608 |
Second Address | Seattle, WA 98122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2006 |
Last Update Date | 01/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1006928 | (05) | WA |
1295703221 | (05) | WA |
8360471 | (05) | WA |