Provider Demographics
NPI:1780794628
Name:ERICKSON, KATHRYN W (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:W
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14030 NE 24TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007
Mailing Address - Country:US
Mailing Address - Phone:425-454-1104
Mailing Address - Fax:425-454-1290
Practice Address - Street 1:14030 NE 24TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007
Practice Address - Country:US
Practice Address - Phone:425-454-1104
Practice Address - Fax:425-454-1290
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024514207N00000X, 207NS0135X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Not Answered207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1068824Medicaid
WACN9262OtherRAILROAD MEDICARE GROUP
WA7080237Medicaid
WA4291030OtherAETNA
WAER1189OtherREGENCE
F00912Medicare UPIN