Provider Demographics
NPI:1053097295
Name:ERICKSON, HAIYDEN LAKE
Entity type:Individual
Prefix:
First Name:HAIYDEN
Middle Name:LAKE
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 COVENTRY DR
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-3632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5241 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93740-0001
Practice Address - Country:US
Practice Address - Phone:530-403-6020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program