Basic Information
| Provider Information | |||||||||
| NPI: | 1710912340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERIKSSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | PETERSON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 9TH AVE | ||||||||
| Address2: | MS:M4-PFS | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 33501 1ST WAY S | ||||||||
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| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538382400 | ||||||||
| FaxNumber: | 2538741637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MD00040728 | WA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 8329310 | 05 | WA | MEDICAID | 8116ER | 01 | WA | BLUE SHIELD | OTHER | MD1251W | 01 | WA | ALASKA MEDICAID | OTHER | 0039572 | 01 | WA | LABOR & INDUSTRY | OTHER | US5051515 | 01 | WA | AETNA/USHC SPECIALIST | OTHER |