Provider Demographics
NPI:1558957811
Name:EDSTROM, TRENT W (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:W
Last Name:EDSTROM
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6622 N 91ST AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2569
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3315
Practice Address - Street 1:4901 W MCDOWELL RD STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-4160
Practice Address - Country:US
Practice Address - Phone:623-849-9088
Practice Address - Fax:623-849-9065
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ233523363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ087425Medicaid