Basic Information
| Provider Information | |||||||||
| NPI: | 1043554520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45390 GREEN AVE | ||||||||
| Address2: | |||||||||
| City: | CALLAHAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320113711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048791223 | ||||||||
| FaxNumber: | 9042774177 | ||||||||
| Practice Location | |||||||||
| Address1: | 45390 GREEN AVE | ||||||||
| Address2: | |||||||||
| City: | CALLAHAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320113711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048791223 | ||||||||
| FaxNumber: | 9042774177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA23801 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | PTA23801 | 01 | FL | STATE OF FLORIDA | OTHER |