Provider Demographics
NPI:1285788018
Name:EDWARDS III, FRED
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:EDWARDS III
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23343 W ASHLEIGH MARIE DR
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-6290
Mailing Address - Country:US
Mailing Address - Phone:619-871-4401
Mailing Address - Fax:
Practice Address - Street 1:23343 W ASHLEIGH MARIE DR
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-6290
Practice Address - Country:US
Practice Address - Phone:619-871-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10294373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ964058Medicaid