Provider Demographics
NPI:1184023400
Name:EDWARDS, JUSTIN G (PA)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:G
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:979 E 3RD ST STE C225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-3314
Mailing Address - Country:US
Mailing Address - Phone:423-778-5995
Mailing Address - Fax:423-778-3445
Practice Address - Street 1:979 E 3RD ST STE C225
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-3314
Practice Address - Country:US
Practice Address - Phone:423-778-5995
Practice Address - Fax:423-778-3445
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA2874363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPA2874OtherMEDICAL LICENSE
AL511-53127OtherBCBS
AL164342Medicaid