Provider Demographics
NPI:1790200392
Name:EDWARDS, RONALD MARK (FNP-BC)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:MARK
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 JACKIE RD SE STE 500
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6607
Mailing Address - Country:US
Mailing Address - Phone:505-415-0719
Mailing Address - Fax:505-372-0093
Practice Address - Street 1:1316 JACKIE RD SE STE 500
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6607
Practice Address - Country:US
Practice Address - Phone:505-415-0719
Practice Address - Fax:505-415-0719
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03324363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily