Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology | PT33795 | FL |
NPI | 1639652167 |
---|---|
Provider Name | Dr. Brian Stuart Ericksen |
First Address | Orange Park, FL 32073-3132 |
Second Address | Orange Park, FL 32073-3132 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2018 |
Last Update Date | 11/09/2018 |