Basic Information
| Provider Information | |||||||||
| NPI: | 1417213802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRIDGEN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 WELCH RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 WELCH RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208200000X | A127478 | CA | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.