Healthcare Provider Details

I. General information

NPI: 1013257385
Provider Name (Legal Business Name): CAROLYN EDLUND PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 S INDIANA AVE
ENGLEWOOD FL
34223-3705
US

IV. Provider business mailing address

1514 NIRA ST
JACKSONVILLE FL
32207-8652
US

V. Phone/Fax

Practice location:
  • Phone: 941-474-8811
  • Fax:
Mailing address:
  • Phone: 904-387-4991
  • Fax: 904-384-3613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107110
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9107110
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: