Provider Demographics
NPI:1922597038
Name:PEARSON, EDWARD LEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LEE
Last Name:PEARSON
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 EDEN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49649-9289
Mailing Address - Country:US
Mailing Address - Phone:231-620-5408
Mailing Address - Fax:
Practice Address - Street 1:320 HUBBARD ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-1926
Practice Address - Country:US
Practice Address - Phone:989-681-6668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206310207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704206310OtherNURSE PRACTITIONER SPECIALTY CERTIFICATION