Provider Demographics
NPI:1134803265
Name:EDWARDS, SAB (CNA)
Entity type:Individual
Prefix:
First Name:SAB
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 N 96TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-1063
Mailing Address - Country:US
Mailing Address - Phone:623-248-4100
Mailing Address - Fax:623-248-1534
Practice Address - Street 1:15639 N VERDE ST
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-4168
Practice Address - Country:US
Practice Address - Phone:623-248-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLH10671172V00000X, 253J00000X, 251S00000X, 261QM0850X, 261QR0405X, 261QR0800X
AZ347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No253J00000XAgenciesFoster Care AgencyGroup - Multi-Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ132133Medicaid