Provider Demographics
NPI:1720255847
Name:HAIRSTON, EDRIAN J (MS ATC LAT)
Entity Type:Individual
Prefix:MR
First Name:EDRIAN
Middle Name:J
Last Name:HAIRSTON
Suffix:
Gender:M
Credentials:MS ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W SEMINOLE BLVD
Mailing Address - Street 2:APT 150
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1200
Mailing Address - Country:US
Mailing Address - Phone:386-822-7166
Mailing Address - Fax:
Practice Address - Street 1:STETSON UNIVERSITY 421 N WOODLAND BLVD
Practice Address - Street 2:UNIT 8317
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32723-0001
Practice Address - Country:US
Practice Address - Phone:386-822-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 24552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer