Provider Demographics
NPI:1245600568
Name:EDISON, BRIAN ERIN (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ERIN
Last Name:EDISON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26871 ALESSANDRO BLVD
Mailing Address - Street 2:SPACE 35
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3903
Mailing Address - Country:US
Mailing Address - Phone:760-610-9362
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE STE 107
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-4289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant