Provider Demographics
NPI:1790026326
Name:EDWARDS, BETH ALLAN (PA)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ALLAN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FOUNTAIN PLAZA
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202
Mailing Address - Country:US
Mailing Address - Phone:716-308-2557
Mailing Address - Fax:
Practice Address - Street 1:6 FOUNTAIN PLZ
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-2211
Practice Address - Country:US
Practice Address - Phone:716-308-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant