Provider Demographics
NPI:1073978680
Name:CONDEZ, EDSEL (PA, MMS)
Entity Type:Individual
Prefix:MR
First Name:EDSEL
Middle Name:
Last Name:CONDEZ
Suffix:
Gender:M
Credentials:PA, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W I ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3479
Mailing Address - Country:US
Mailing Address - Phone:209-826-2222
Mailing Address - Fax:
Practice Address - Street 1:9710 BRIMHALL RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2779
Practice Address - Country:US
Practice Address - Phone:661-829-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-24
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.PA.60615465363A00000X
CA53129363A00000X
WAPA60615465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant