Provider Demographics
NPI:1215598438
Name:ERICKSON, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
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 1:502 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-8436
Mailing Address - Country:US
Mailing Address - Phone:918-404-9906
Mailing Address - Fax:
Practice Address - Street 1:502 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-8436
Practice Address - Country:US
Practice Address - Phone:918-404-9906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist