=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992795041
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL EDWARDS P.A.-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2005
-----------------------------------------------------
Last Update Date | 06/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 S MAIN ST STE A
-----------------------------------------------------
City | BLADENBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28320-8440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-809-0030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 88
-----------------------------------------------------
City | BLADENBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28320-0088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-809-0030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 103768
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------