Basic Information
| Provider Information | |||||||||
| NPI: | 1164683777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICHSEN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291253 | ||||||||
| FaxNumber: | 3607293185 | ||||||||
| Practice Location | |||||||||
| Address1: | 3377 RIVERBEND DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974778803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412222402 | ||||||||
| FaxNumber: | 5412222350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD176442 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080S0012X | MD176442 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500711175 | 05 | OR | MEDICAID |