Provider Demographics
NPI:1578286373
Name:FERGUSON, BRIAN (ASSOCIATES)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:ASSOCIATES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9892 HAMLET CT S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4833
Mailing Address - Country:US
Mailing Address - Phone:612-876-8874
Mailing Address - Fax:
Practice Address - Street 1:300 FOUNTAINGROVE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5720
Practice Address - Country:US
Practice Address - Phone:707-566-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50328225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant