Provider Demographics
NPI:1235338799
Name:EDGAR, ROBERT PAUL (LPN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:PAUL
Last Name:EDGAR
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3411
Mailing Address - Country:US
Mailing Address - Phone:315-782-8876
Mailing Address - Fax:
Practice Address - Street 1:30204 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:BLACK RIVER
Practice Address - State:NY
Practice Address - Zip Code:13612-2091
Practice Address - Country:US
Practice Address - Phone:315-773-9012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-15
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226744-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02457972Medicaid