Provider Demographics
NPI:1992795041
Name:EDWARDS, CRYSTAL (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
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:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:BLADENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28320-0088
Mailing Address - Country:US
Mailing Address - Phone:910-809-0030
Mailing Address - Fax:
Practice Address - Street 1:125 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BLADENBORO
Practice Address - State:NC
Practice Address - Zip Code:28320-8440
Practice Address - Country:US
Practice Address - Phone:910-809-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NC103768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8941520Medicaid
NC02703OtherBCBS
NCP96520Medicare UPIN
NC2759276Medicare ID - Type Unspecified