Basic Information
| Provider Information | |||||||||
| NPI: | 1316401870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDGMON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | REGISTERED NURSE | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | RR 6 BOX 840 | ||||||||
| Address2: | |||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749608703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968800 | ||||||||
| FaxNumber: | 9186968840 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 6 BOX 840 | ||||||||
| Address2: | |||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749608703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968800 | ||||||||
| FaxNumber: | 9186968840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2019 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WI0600X | 121570 | OK | Y | Nursing Service Providers | Registered Nurse | Infection Control |
No ID Information.