Provider Demographics
NPI:1760856231
Name:EDWARDS, CLIFTON A J (MHA,REEGT,PMP, CPHQ)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:A J
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MHA,REEGT,PMP, CPHQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 NE SANDY BLVD # 367
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:971-227-9340
Mailing Address - Fax:864-364-5280
Practice Address - Street 1:3347 NE 164TH LOOP
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5063
Practice Address - Country:US
Practice Address - Phone:971-227-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-21
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
#3283: R. EEG T.246ZE0500X
#847: R. EP T.246Z00000X
#3726: RPSGT246Z00000X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic