Provider Demographics
NPI:1275558934
Name:STAAT, EDWIN PAUL (APRN)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:PAUL
Last Name:STAAT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-578-3204
Mailing Address - Fax:859-578-3273
Practice Address - Street 1:513 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-1562
Practice Address - Country:US
Practice Address - Phone:859-331-3292
Practice Address - Fax:859-578-2864
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYP3831363LA2200X, 363LX0001X
KYP3003831363LF0000X
OH16864-NP363LF0000X
KY3003831363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID