Provider Demographics
NPI:1881643393
Name:LANDON, ERIC (NP)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:LANDON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6705
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6705
Mailing Address - Country:US
Mailing Address - Phone:228-865-1330
Mailing Address - Fax:
Practice Address - Street 1:3401 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-5101
Practice Address - Country:US
Practice Address - Phone:228-762-7451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1116211363L00000X
MSR860220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1116211Medicaid
LA1116211Medicaid
LAQ29850Medicare UPIN
LA4H237CH88Medicare ID - Type UnspecifiedLA001
LA4H237CT60Medicare ID - Type UnspecifiedLA099