Provider Demographics
NPI:1508034588
Name:EDENS, JAMIE F (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:F
Last Name:EDENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:I
Other - Last Name:FANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:610 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2372
Mailing Address - Country:US
Mailing Address - Phone:505-242-3991
Mailing Address - Fax:505-243-8405
Practice Address - Street 1:610 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2372
Practice Address - Country:US
Practice Address - Phone:505-242-3991
Practice Address - Fax:505-243-8405
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0028363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96972351Medicaid
NM96972351Medicaid