Provider Demographics
NPI:1548589930
Name:EDWARDS, SCOTT MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:EDWARDS
Suffix:
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 1:12900 CORTEZ BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6828
Mailing Address - Country:US
Mailing Address - Phone:352-596-1117
Mailing Address - Fax:
Practice Address - Street 1:12900 CORTEZ BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6828
Practice Address - Country:US
Practice Address - Phone:352-596-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105274363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical