Provider Demographics
NPI:1376836981
Name:ERICSON, TIMOTHY A (FNP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:ERICSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-0278
Mailing Address - Country:US
Mailing Address - Phone:971-983-5260
Mailing Address - Fax:971-983-5326
Practice Address - Street 1:1475 MT HOOD AVE.
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071
Practice Address - Country:US
Practice Address - Phone:503-982-2174
Practice Address - Fax:503-982-4599
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2017-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 20561363L00000X
OR201394165NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner