Provider Demographics
NPI:1588696520
Name:SPROWL, EDWARD MANNING III (PAC)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:MANNING
Last Name:SPROWL
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 ABALONE LOOP
Mailing Address - Street 2:
Mailing Address - City:MESCALERO
Mailing Address - State:NM
Mailing Address - Zip Code:88340
Mailing Address - Country:US
Mailing Address - Phone:575-464-4441
Mailing Address - Fax:
Practice Address - Street 1:318 ABALONE LOOP
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340
Practice Address - Country:US
Practice Address - Phone:575-464-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1016599363A00000X
PAMA001481L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM38553562Medicaid
AZ846537Medicaid
NM38553562Medicaid
AZ846537Medicaid