Provider Demographics
NPI:1164580270
Name:ERICKSON, REBECCA SUE (OCULARIST)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:OCULARIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:SUITE 1421
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1749
Mailing Address - Country:US
Mailing Address - Phone:206-622-9175
Mailing Address - Fax:206-622-9378
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:SUITE 1421
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1749
Practice Address - Country:US
Practice Address - Phone:206-622-9175
Practice Address - Fax:206-622-9378
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOS 00000016156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9111006Medicaid
WA9111006Medicaid