Provider Demographics
NPI:1578850046
Name:EDMONSON, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:EDMONSON
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 1:3800 AMERICAN BLVD W
Mailing Address - Street 2:STE 200
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4420
Mailing Address - Country:US
Mailing Address - Phone:952-831-8742
Mailing Address - Fax:952-831-1626
Practice Address - Street 1:3800 AMERICAN BLVD W
Practice Address - Street 2:STE 200
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4420
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:952-831-1626
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9381174400000X
MN87112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist