Healthcare Provider Details

I. General information

NPI: 1528034543
Provider Name (Legal Business Name): RICHARD MAURICE EDWARDS JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COMMERCE LANE CP FAMILY HEALTH CENTER
CANTON NY
13617
US

IV. Provider business mailing address

7991 US HIGHWAY 11
POTSDAM NY
13676-3239
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-8791
  • Fax: 315-386-1410
Mailing address:
  • Phone: 315-212-9368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000591
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: