Basic Information
| Provider Information | |||||||||
| NPI: | 1982672655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | RN MSN FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 HIGHWAY 83 NORTH | ||||||||
| Address2: | |||||||||
| City: | SEELEY LAKE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598681380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066772277 | ||||||||
| FaxNumber: | 4066772387 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 RAILROAD ST W | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062584789 | ||||||||
| FaxNumber: | 4062584732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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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 | 363L00000X | 38495 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000384684 | 01 | IN | ANTHEM | OTHER | 200202960A | 05 | IN | MEDICAID | 19822672655 | 05 | MT | MEDICAID |