Provider Demographics
NPI:1164497954
Name:EDWARDS, PHYLLIS ANN (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ANN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 W NOBLE AVE
Mailing Address - Street 2:PMB 323
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-1662
Mailing Address - Country:US
Mailing Address - Phone:503-445-2034
Mailing Address - Fax:503-216-2488
Practice Address - Street 1:100 WILLOW PLAZA
Practice Address - Street 2:STE 301
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6215
Practice Address - Country:US
Practice Address - Phone:559-734-3278
Practice Address - Fax:559-627-5723
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62111208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G621111Medicare PIN
C46722Medicare UPIN