Provider Demographics
NPI:1871032615
Name:EDWARDS, MYRA (MT)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10598 BLUE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 ELM ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9164
Practice Address - Country:US
Practice Address - Phone:715-358-6650
Practice Address - Fax:715-358-6381
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27-146174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist