Provider Demographics
NPI:1225655251
Name:MAGNUSON, ERIC DALE (SIDPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DALE
Last Name:MAGNUSON
Suffix:
Gender:M
Credentials:SIDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 HOYT AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2348
Mailing Address - Country:US
Mailing Address - Phone:425-268-6212
Mailing Address - Fax:
Practice Address - Street 1:1305 SENECA ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2828
Practice Address - Country:US
Practice Address - Phone:206-323-0934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60899549390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program