Provider Demographics
NPI:1265473078
Name:WILKINS, EDWARD T (CRNA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:T
Last Name:WILKINS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 TOPAZ DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4035
Mailing Address - Country:US
Mailing Address - Phone:321-637-9197
Mailing Address - Fax:321-637-9197
Practice Address - Street 1:719 E NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5459
Practice Address - Country:US
Practice Address - Phone:321-726-4024
Practice Address - Fax:321-984-9547
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN326069L367500000X, 163W00000X
SC2511367500000X
FLARNP9215859367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA44192443603Medicaid
FL306717300Medicaid
PA063632FEVMedicare ID - Type Unspecified
FL306717300Medicaid
PA44192443603Medicaid