Provider Demographics
NPI:1194716241
Name:EDWARDS, CLYDE RICHARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:RICHARD
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1655 WAKE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4745
Mailing Address - Country:US
Mailing Address - Phone:919-556-4779
Mailing Address - Fax:919-556-5277
Practice Address - Street 1:1655 WAKE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4745
Practice Address - Country:US
Practice Address - Phone:919-556-4779
Practice Address - Fax:919-556-5277
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC102843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC102843OtherNORTH CAROLINA LICENSE