Provider Demographics
NPI:1063911196
Name:EDELMAN, WILLIAM (PA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:EDELMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4485 FURLING LN
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5331
Mailing Address - Country:US
Mailing Address - Phone:850-654-1194
Mailing Address - Fax:
Practice Address - Street 1:4485 FURLING LN
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5331
Practice Address - Country:US
Practice Address - Phone:850-654-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9100677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant