Healthcare Provider Details

I. General information

NPI: 1578052973
Provider Name (Legal Business Name): DEVIN LEE MICHAEL EDWARDS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MOONBOW PLZ
CORBIN KY
40701
US

IV. Provider business mailing address

PO BOX 1325
CORBIN KY
40702-1325
US

V. Phone/Fax

Practice location:
  • Phone: 606-523-9010
  • Fax:
Mailing address:
  • Phone: 606-526-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC714
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: