Provider Demographics
NPI:1801937859
Name:WILSON-EDWARDS, ALICE R
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:R
Last Name:WILSON-EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SPRUCE STREET
Mailing Address - Street 2:PINE BASEMENT WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6130
Mailing Address - Country:US
Mailing Address - Phone:215-829-3264
Mailing Address - Fax:
Practice Address - Street 1:700 SPRUCE STREET
Practice Address - Street 2:PINE BASEMENT WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003416363AS0400X
PAMA053836363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical