Provider Demographics
NPI:1528108123
Name:EDMONDSON, PATRICK JAMES (PT)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JAMES
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 W ALAMEDA AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4806
Mailing Address - Country:US
Mailing Address - Phone:818-845-9010
Mailing Address - Fax:818-845-4300
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4806
Practice Address - Country:US
Practice Address - Phone:818-845-9010
Practice Address - Fax:818-845-4300
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7517225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT7517Medicare ID - Type Unspecified
R62782Medicare UPIN