Provider Demographics
NPI:1417213802
Name:PRIDGEN, BRIAN CRAIG
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CRAIG
Last Name:PRIDGEN
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 1:770 WELCH RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1511
Mailing Address - Country:US
Mailing Address - Phone:111-111-1111
Mailing Address - Fax:
Practice Address - Street 1:770 WELCH RD
Practice Address - Street 2:SUITE 400
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1511
Practice Address - Country:US
Practice Address - Phone:111-111-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA127478208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program