Provider Demographics
NPI:1588763007
Name:EDISON, GINA LYNN (NP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:LYNN
Last Name:EDISON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 SOUTH MAPLE ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387
Mailing Address - Country:US
Mailing Address - Phone:952-856-4003
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-4551
Practice Address - Country:US
Practice Address - Phone:952-556-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128639363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41177800Medicaid
WI41177800Medicaid
Q00815Medicare UPIN