Basic Information
| Provider Information | |||||||||
| NPI: | 1881963106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDOUARD | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY | ||||||||
| Address2: | STE301 | ||||||||
| City: | N FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 CAPE CORAL PKWY W STE I | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339146985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395401495 | ||||||||
| FaxNumber: | 2395491080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2011 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106374 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.