Basic Information
| Provider Information | |||||||||
| NPI: | 1265999056 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 E 5350 S | ||||||||
| Address2: | STE 205 | ||||||||
| City: | WASHINGTON TERRACE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11011 MERIDIAN AVE N STE 201 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066686361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2019 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 11111343-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA60942025 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1265999056 | 05 | WA | MEDICAID |