Healthcare Provider Details

I. General information

NPI: 1811209893
Provider Name (Legal Business Name): ERIK TYLER FREDLUND PA-C, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 BROOKHAVEN VW NE
BROOKHAVEN GA
30319-3198
US

IV. Provider business mailing address

2602 BROOKHAVEN VW NE
BROOKHAVEN GA
30319-3198
US

V. Phone/Fax

Practice location:
  • Phone: 404-374-0116
  • Fax:
Mailing address:
  • Phone: 404-374-0116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: