Healthcare Provider Details

I. General information

NPI: 1083108419
Provider Name (Legal Business Name): BRIAN ROY ERICKSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 WELLNESS BLVD STE 110&210
MONROE NC
28110-7769
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1140
  • Fax: 704-384-1141
Mailing address:
  • Phone: 704-384-9200
  • Fax: 704-384-6588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5010628
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5010628
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: