Healthcare Provider Details

I. General information

NPI: 1922597038
Provider Name (Legal Business Name): EDWARD LEE PEARSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 HUBBARD ST
SAINT LOUIS MI
48880-1926
US

IV. Provider business mailing address

363 EDEN ST
KINGSLEY MI
49649-9289
US

V. Phone/Fax

Practice location:
  • Phone: 989-681-6668
  • Fax:
Mailing address:
  • Phone: 231-620-5408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4704206310
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: