Provider Demographics
NPI:1912067521
Name:ERICSON, SHASTA (LAC, DAOM)
Entity Type:Individual
Prefix:DR
First Name:SHASTA
Middle Name:
Last Name:ERICSON
Suffix:
Gender:F
Credentials:LAC, DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 SARATOGA AVE SUITE 104
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129
Mailing Address - Country:US
Mailing Address - Phone:408-615-1995
Mailing Address - Fax:408-615-1999
Practice Address - Street 1:940 SARATOGA AVE SUITE 104
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129
Practice Address - Country:US
Practice Address - Phone:408-615-1995
Practice Address - Fax:408-615-1999
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5149171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
77041-5394OtherTAX ID