MEDICARE: MRS. MICHELE MARIE EDWARDS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1487673075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELE MARIE EDWARDS PA-C

Provider Business Mailing Address
First Line	:	PO BOX 238
Second Line	:	156 BOOMER COMMUNITY CENTER RD.
City	:	BOOMER
State	:	NC
Zip	:	28606-0238
Country	:	US
Telephone Number	:	336-921-2273
Fax Number	:	336-921-2405

Provider Business Practice Location Address
First Line	:	156 BOOMER COMMUNITY CENTER RD
Second Line	:
City	:	BOOMER
State	:	NC
Zip	:	28606-9199
Country	:	US
Telephone Number	:	336-921-2273
Fax Number	:	336-921-2405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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