Healthcare Provider Details

I. General information

NPI: 1275558934
Provider Name (Legal Business Name): EDWIN PAUL STAAT APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 MADISON AVE
COVINGTON KY
41011-1562
US

IV. Provider business mailing address

502 FARRELL DR
COVINGTON KY
41011-3717
US

V. Phone/Fax

Practice location:
  • Phone: 859-331-3292
  • Fax: 859-578-2864
Mailing address:
  • Phone: 859-578-3204
  • Fax: 859-578-3273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberP3831
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberP3003831
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16864-NP
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberP3831
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3003831
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: