Healthcare Provider Details

I. General information

NPI: 1508034588
Provider Name (Legal Business Name): JAMIE F EDENS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMIE I FANNING PA-C

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

IV. Provider business mailing address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-3991
  • Fax: 505-243-8405
Mailing address:
  • Phone: 505-242-3991
  • Fax: 505-243-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2009-0028
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: