Provider Demographics
NPI:1891893442
Name:WILLS, TERESA ANN ERICKSON (OD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN ERICKSON
Last Name:WILLS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TERESA
Other - Middle Name:A
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:900 MERIDIAN E STE 18
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-7003
Mailing Address - Country:US
Mailing Address - Phone:253-927-5252
Mailing Address - Fax:253-927-4270
Practice Address - Street 1:900 MERIDIAN E STE 18
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-7003
Practice Address - Country:US
Practice Address - Phone:253-927-5252
Practice Address - Fax:253-927-4270
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2027316Medicaid
WA2027316Medicaid
WAG8879827Medicare PIN