Provider Demographics
NPI:1477792844
Name:EDMONDS MEDICAL, LLC
Entity Type:Organization
Organization Name:EDMONDS MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:225-810-3430
Mailing Address - Street 1:5445 LA SIERRA DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4139
Mailing Address - Country:US
Mailing Address - Phone:214-382-1909
Mailing Address - Fax:214-382-1903
Practice Address - Street 1:3111 LONGLEAF CT
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-0308
Practice Address - Country:US
Practice Address - Phone:225-810-3430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10599363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty