Provider Demographics
NPI:1619945144
Name:EDGE, WILLIAM KIRBY (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KIRBY
Last Name:EDGE
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 1:12888 MEADOW BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-2014
Mailing Address - Country:US
Mailing Address - Phone:561-389-5907
Mailing Address - Fax:561-333-0832
Practice Address - Street 1:1309 N FLAGLER DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-3406
Practice Address - Country:US
Practice Address - Phone:561-655-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1309TMedicare ID - Type UnspecifiedMEDICARE
FLS64375Medicare UPIN