Provider Demographics
NPI:1588734750
Name:POWELL, EDWARD JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JAMES
Last Name:POWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85228-4405
Mailing Address - Country:US
Mailing Address - Phone:520-723-7726
Mailing Address - Fax:520-723-4513
Practice Address - Street 1:171 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85228-4405
Practice Address - Country:US
Practice Address - Phone:520-723-7726
Practice Address - Fax:520-723-4513
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ740052Medicaid
AZ03D09444436OtherCLIA
AZMP0008222OtherDEA
AZMP0008222OtherDEA
AZ03D09444436OtherCLIA