Doctor Name: | JONATHAN EDWARDS |
NPI Number: | 1164820312 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | 209012330 |
Business Practice Address: | 1405 E 12th St Suite 600 Mendota, IL - 613429010 |
Business Phone Number: | 8155387200 |
Business Fax Number: | 8155391444 |
Mailing Address: | 1405 E 12th St, Suite 600 MENDOTA |
State: | IL |
Postal Code: | 613429010 |
Phone Number: | 8155387200 |
Fax Number: | 8155391444 |
NPI Enumeration Date: | 12/19/2014 |
NPI Last Update Date: | 12/19/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | 209012330 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |