Provider Demographics
NPI:1912356494
Name:EDWARDS, NATHAN TYLER (CRNA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:TYLER
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 W SCHUBERT AVE
Mailing Address - Street 2:APT. 1-O
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1320
Mailing Address - Country:US
Mailing Address - Phone:256-658-9848
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:256-658-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN186574163W00000X
IL209.014949163W00000X
IL041.442743367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse