MEDICARE: ERIC DALE MAGNUSON SIDPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	CO60899549	WA

General Provider Information

NPI Number	:	1225655251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC DALE MAGNUSON SIDPT

Provider Business Mailing Address
First Line	:	4415 HOYT AVE APT 1
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98203-2348
Country	:	US
Telephone Number	:	425-268-6212
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 SENECA ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98101-2828
Country	:	US
Telephone Number	:	206-323-0934
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	06/25/2020

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