Basic Information
| Provider Information | |||||||||
| NPI: | 1194720672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1096 OLD CHURCHMANS RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026559494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1096 OLD CHURCHMANS RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026559494 | ||||||||
| FaxNumber: | 3026234147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C50000228 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00110729 | 01 | DE | RAILROAD MEDICARE | OTHER | 16225 | 01 | DE | MID-ATLANTIC | OTHER | P02567 | 01 | DE | COVENTRY | OTHER | P02567 | 01 | DE | BCBS | OTHER |