Provider Demographics
NPI:1275207607
Name:EDWARDS, BRENT ANDREW
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ANDREW
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 SW OLD WIRE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-4089
Mailing Address - Country:US
Mailing Address - Phone:352-231-5377
Mailing Address - Fax:
Practice Address - Street 1:560 SW MCFARLANE AVE FL 32025
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5614
Practice Address - Country:US
Practice Address - Phone:386-758-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30593225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant