Provider Demographics
NPI:1447420328
Name:EDSTROM, BOBBI S (PA)
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:S
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:KINDER
Mailing Address - State:LA
Mailing Address - Zip Code:70648-3187
Mailing Address - Country:US
Mailing Address - Phone:337-738-9494
Mailing Address - Fax:
Practice Address - Street 1:108 6TH AVE
Practice Address - Street 2:
Practice Address - City:KINDER
Practice Address - State:LA
Practice Address - Zip Code:70648-3187
Practice Address - Country:US
Practice Address - Phone:337-738-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101513363A00000X
LAPA200640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant