Provider Demographics
NPI:1609107846
Name:EDMONDSON, JUSTIN R
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:R
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:
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 7627
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36670-0627
Mailing Address - Country:US
Mailing Address - Phone:251-633-7211
Mailing Address - Fax:251-410-6079
Practice Address - Street 1:2350 SCHILLINGER RD S
Practice Address - Street 2:SUITE A
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4177
Practice Address - Country:US
Practice Address - Phone:251-633-0123
Practice Address - Fax:251-633-0123
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.671363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical