Provider Demographics
NPI:1972160612
Name:ERICKSON, MONICA D (BCO)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:D
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W RIVERSIDE AVE STE 770
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0402
Mailing Address - Country:US
Mailing Address - Phone:509-747-6148
Mailing Address - Fax:509-638-6705
Practice Address - Street 1:421 W RIVERSIDE AVE STE 770
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0402
Practice Address - Country:US
Practice Address - Phone:509-747-6148
Practice Address - Fax:509-638-6705
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOS60696687156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003137000Medicaid
MT566943Medicaid
WA9028838Medicaid