Healthcare Provider Details

I. General information

NPI: 1730410937
Provider Name (Legal Business Name): JASON MICHAEL EDWARDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 09/24/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 626 KADENA AB
APO AP
96367
US

IV. Provider business mailing address

BLDG 626 SGH OFFICE
APO AP
96367
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01070914A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: