Basic Information
| Provider Information | |||||||||
| NPI: | 1063910933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | ANDY | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 7050 UNION PARK CENTER | ||||||||
| Address2: | #200 | ||||||||
| City: | MIDVALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840474171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2018 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 8650489-3102 | UT | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 8560489-4405 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 8650489-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.