Provider Demographics
NPI:1700879871
Name:EDWARDS, ALAN E (PA)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:E
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E SAINT PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5907
Mailing Address - Country:US
Mailing Address - Phone:414-223-2727
Mailing Address - Fax:414-223-2724
Practice Address - Street 1:625 E SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5907
Practice Address - Country:US
Practice Address - Phone:414-223-2727
Practice Address - Fax:414-223-2724
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI305023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0161800001Medicare NSC