Basic Information
Provider Information | |||||||||
NPI: | 1063590305 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDWARDS | ||||||||
FirstName: | PAMALA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 204 E 1ST ST | ||||||||
Address2: |   | ||||||||
City: | ALICE | ||||||||
State: | TX | ||||||||
PostalCode: | 783324822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3616640145 | ||||||||
FaxNumber: | 3616642248 | ||||||||
Practice Location | |||||||||
Address1: | 700 FLOURNOY RD | ||||||||
Address2: | SUITE 2A | ||||||||
City: | ALICE | ||||||||
State: | TX | ||||||||
PostalCode: | 783324003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3616641417 | ||||||||
FaxNumber: | 3616643218 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 08/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA02621 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 063476801 | 05 | TX |   | MEDICAID | 312414101 | 05 | TX |   | MEDICAID | 8J3360 | 01 | TX | MEDICARE PARTB FOR COMMUNITY ACTION | OTHER |