Provider Demographics
NPI:1881688810
Name:EDWARDS, AMY S (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 S LAKE CREST WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7142
Mailing Address - Country:US
Mailing Address - Phone:208-939-9131
Mailing Address - Fax:208-345-1890
Practice Address - Street 1:1636 S LAKE CREST WAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7142
Practice Address - Country:US
Practice Address - Phone:208-939-9131
Practice Address - Fax:208-345-1890
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-114102084P0800X
WAMD000481402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8484347Medicaid
WAI40724Medicare UPIN
WA8484347Medicaid
ID20000153Medicare PIN