Provider Demographics
NPI:1689554032
Name:EDBLAD, PETER VERNON (PA-C)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:VERNON
Last Name:EDBLAD
Suffix:
Gender:X
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 1:3032 SHADES VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-7438
Mailing Address - Country:US
Mailing Address - Phone:763-670-5725
Mailing Address - Fax:
Practice Address - Street 1:655 JESSE JEWELL PKWY SE STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3854
Practice Address - Country:US
Practice Address - Phone:678-207-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty