Provider Demographics
NPI:1558967976
Name:EDMA, MARC DANIEL
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:DANIEL
Last Name:EDMA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARC
Other - Middle Name:DANIEL
Other - Last Name:EDMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:435 53RD ST APT D5
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-2058
Mailing Address - Country:US
Mailing Address - Phone:201-455-9825
Mailing Address - Fax:
Practice Address - Street 1:435 53RD ST APT D5
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2058
Practice Address - Country:US
Practice Address - Phone:201-455-9825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07398600164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse