Healthcare Provider Details

I. General information

NPI: 1093218968
Provider Name (Legal Business Name): BRIAN EMERSON NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ORTHOPAEDIC PL
SAINT AUGUSTINE FL
32086-4202
US

IV. Provider business mailing address

1 ORTHOPAEDIC PL
SAINT AUGUSTINE FL
32086-4202
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-0540
  • Fax: 904-825-2490
Mailing address:
  • Phone: 904-825-0540
  • Fax: 904-825-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF03180173
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: