Healthcare Provider Details

I. General information

NPI: 1194720672
Provider Name (Legal Business Name): THOMAS EDWARDS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 OLD CHURCHMANS RD
NEWARK DE
19713-2102
US

IV. Provider business mailing address

1096 OLD CHURCHMANS RD
NEWARK DE
19713-2102
US

V. Phone/Fax

Practice location:
  • Phone: 302-655-9494
  • Fax: 302-623-4147
Mailing address:
  • Phone: 302-655-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC50000228
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: