Provider Demographics
NPI:1639374671
Name:EDISS, CHRIS EDMUND (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:EDMUND
Last Name:EDISS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17282 MINDEN DR
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-3219
Mailing Address - Country:US
Mailing Address - Phone:714-993-6193
Mailing Address - Fax:
Practice Address - Street 1:7601 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3456
Practice Address - Country:US
Practice Address - Phone:562-401-7115
Practice Address - Fax:562-401-6247
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant