Basic Information
| Provider Information | |||||||||
| NPI: | 1538822481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDMUNDS | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2930 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806201011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703504602 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2930 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806201011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703539403 | ||||||||
| FaxNumber: | 9703535884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2021 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0007141 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.