Provider Demographics
NPI:1184714206
Name:EDWARDS-BRAITHWAITE, RHONDA R (PA)
Entity type:Individual
Prefix:
First Name:RHONDA
Middle Name:R
Last Name:EDWARDS-BRAITHWAITE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RHONDA
Other - Middle Name:R
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1738 WISTERIA CIR
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-3046
Mailing Address - Country:US
Mailing Address - Phone:631-618-1255
Mailing Address - Fax:
Practice Address - Street 1:465 SMITHTOWN BLVD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2421
Practice Address - Country:US
Practice Address - Phone:631-676-6700
Practice Address - Fax:631-676-6700
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03649685Medicaid
NYP93295Medicare UPIN