Provider Demographics
NPI:1023886397
Name:EDWARDS, CHRISTOPHER LEIF
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LEIF
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N 650 E # 8
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:ID
Mailing Address - Zip Code:83218-7706
Mailing Address - Country:US
Mailing Address - Phone:208-243-4520
Mailing Address - Fax:
Practice Address - Street 1:2330 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-542-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID78244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily