Provider Demographics
NPI:1295744282
Name:EDMONDS, ERNEST WAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:WAYNE
Last Name:EDMONDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4495 HWY 79 S.
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-0535
Mailing Address - Country:US
Mailing Address - Phone:940-691-4360
Mailing Address - Fax:940-723-1890
Practice Address - Street 1:1800 7TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4204
Practice Address - Country:US
Practice Address - Phone:940-723-2373
Practice Address - Fax:940-723-1890
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTX 00973OtherTEXAS LICENSE/PERMIT
TXTX 00973OtherTEXAS LICENSE/PERMIT