Provider Demographics
NPI:1053331272
Name:EDWARDS, REBECCA S (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2484
Mailing Address - Country:US
Mailing Address - Phone:910-763-5182
Mailing Address - Fax:910-763-0291
Practice Address - Street 1:1520 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7356
Practice Address - Country:US
Practice Address - Phone:910-763-5182
Practice Address - Fax:910-763-0291
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1913PAMedicaid
NC8102142Medicaid
NC1053331272Medicaid
NC8102142Medicaid
NC1053331272Medicaid
NCNC8328AMedicare PIN