Provider Demographics
NPI:1225010697
Name:POWELL, EDWARD D (PA-C)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:D
Last Name:POWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 W CHESTNUT ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-4658
Mailing Address - Country:US
Mailing Address - Phone:724-228-1414
Mailing Address - Fax:724-228-8579
Practice Address - Street 1:380 W CHESTNUT ST STE 101
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4658
Practice Address - Country:US
Practice Address - Phone:724-228-1414
Practice Address - Fax:724-228-8579
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000702L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103191740Medicaid
PAS82522Medicare UPIN
PA103191740Medicaid