Provider Demographics
NPI:1205820511
Name:EDWARDS, MONTE (PAC)
Entity Type:Individual
Prefix:
First Name:MONTE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3211
Mailing Address - Country:US
Mailing Address - Phone:352-799-5411
Mailing Address - Fax:352-544-2713
Practice Address - Street 1:605 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3211
Practice Address - Country:US
Practice Address - Phone:352-799-5411
Practice Address - Fax:352-544-2713
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1806363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY01AAOtherBCBS FL
FL290064500Medicaid
FL290064500Medicaid
FLE2620XMedicare PIN
FLE2620AMedicare PIN
FLE2620BMedicare PIN
FLY01AAOtherBCBS FL
FLE2620YMedicare PIN