Basic Information
| Provider Information | |||||||||
| NPI: | 1609107846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDMONDSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7627 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516337211 | ||||||||
| FaxNumber: | 2514106079 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 SCHILLINGER RD S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366954177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330123 | ||||||||
| FaxNumber: | 2516330123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2010 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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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 | 363AM0700X | PA.671 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.