Provider Demographics
NPI:1245278183
Name:ERICKSON, WADE (MD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3066 E MERIDIAN PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7299
Mailing Address - Country:US
Mailing Address - Phone:907-357-9593
Mailing Address - Fax:
Practice Address - Street 1:3066 E MERIDIAN PARK LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7299
Practice Address - Country:US
Practice Address - Phone:907-357-9593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4593207Q00000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD45932Medicaid
AKMD45932Medicaid
AKK152907Medicare ID - Type Unspecified