Provider Demographics
NPI:1619526217
Name:EDOUARD, JEAN SIMON JOEL (PA)
Entity Type:Individual
Prefix:MR
First Name:JEAN
Middle Name:SIMON JOEL
Last Name:EDOUARD
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 1:6739 W CACTUS RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5311
Mailing Address - Country:US
Mailing Address - Phone:520-527-8038
Mailing Address - Fax:
Practice Address - Street 1:6739 W CACTUS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5311
Practice Address - Country:US
Practice Address - Phone:520-527-8038
Practice Address - Fax:623-889-0814
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDCATEMP-000588207Q00000X
WI21-308246ZC0007X
RIPA01253363A00000X
PR000430-P.A363A00000X
NJNJDCATEMP-00291363A00000X
AZ8276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty