Provider Demographics
NPI:1467173880
Name:EDGE, JUSTIN A (ATC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:EDGE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 HARRISON ST APT 14
Mailing Address - Street 2:
Mailing Address - City:NORTH FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-1582
Mailing Address - Country:US
Mailing Address - Phone:608-444-2911
Mailing Address - Fax:
Practice Address - Street 1:45 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4621
Practice Address - Country:US
Practice Address - Phone:920-923-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer