Provider Demographics
NPI:1447759592
Name:EDWARDS, DARRELL DEWAIN
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:DEWAIN
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 1:4350 S NATIONAL AVE STE C200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2782
Mailing Address - Country:US
Mailing Address - Phone:417-447-1000
Mailing Address - Fax:417-447-6150
Practice Address - Street 1:4350 S NATIONAL AVE STE C200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2782
Practice Address - Country:US
Practice Address - Phone:417-447-1000
Practice Address - Fax:417-447-6150
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018002812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant