Provider Demographics
NPI:1528034543
Name:EDWARDS, RICHARD MAURICE JR (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MAURICE
Last Name:EDWARDS
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7991 US HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-3239
Mailing Address - Country:US
Mailing Address - Phone:315-212-9368
Mailing Address - Fax:
Practice Address - Street 1:4 COMMERCE LANE
Practice Address - Street 2:CP FAMILY HEALTH CENTER
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-386-8791
Practice Address - Fax:315-386-1410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S38461Medicare UPIN
PA0229Medicare ID - Type Unspecified