Provider Demographics
NPI:1023157831
Name:GORMANSON, ERIC JON (DC)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JON
Last Name:GORMANSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12818 LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045
Mailing Address - Country:US
Mailing Address - Phone:651-257-2300
Mailing Address - Fax:651-257-2333
Practice Address - Street 1:12818 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045
Practice Address - Country:US
Practice Address - Phone:651-257-2300
Practice Address - Fax:651-257-2333
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7016111N00000X
MO2007029016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
261583971OtherMEDICARE PTAN