Provider Demographics
NPI:1780207795
Name:EDWARDS, OLIVIA S (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:S
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:S
Other - Last Name:FARMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11155 DUNN RD STE 309E
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6111
Mailing Address - Country:US
Mailing Address - Phone:314-953-8799
Mailing Address - Fax:
Practice Address - Street 1:11155 DUNN RD STE 309E
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6111
Practice Address - Country:US
Practice Address - Phone:314-953-8799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021047997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant