Provider Demographics
NPI:1770682189
Name:SQUIRE, EDWARD NOONAN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:NOONAN
Last Name:SQUIRE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 7 LKS N
Mailing Address - Street 2:
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-8362
Mailing Address - Country:US
Mailing Address - Phone:910-673-3673
Mailing Address - Fax:
Practice Address - Street 1:1528 7 LKS N
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376-8362
Practice Address - Country:US
Practice Address - Phone:910-673-3673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801509174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891189QMedicaid
NC891189QMedicaid
G90602Medicare UPIN