Healthcare Provider Details

I. General information

NPI: 1881643393
Provider Name (Legal Business Name): ERIC LANDON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 MAIN ST
MOSS POINT MS
39563-5101
US

IV. Provider business mailing address

PO BOX 6705
GULFPORT MS
39506-6705
US

V. Phone/Fax

Practice location:
  • Phone: 228-762-7451
  • Fax:
Mailing address:
  • Phone: 228-865-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1116211
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR860220
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: