Provider Demographics
NPI:1407815392
Name:PROVO, ERIC LANDRY
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LANDRY
Last Name:PROVO
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 1:8857 1ST ST STE 400
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23511-3713
Mailing Address - Country:US
Mailing Address - Phone:757-445-7256
Mailing Address - Fax:757-576-4161
Practice Address - Street 1:8857 1ST ST STE 400
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-3713
Practice Address - Country:US
Practice Address - Phone:757-445-7256
Practice Address - Fax:757-576-4161
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1710I1002XOtherINDEPENDENT DUTY CORPSMAN