Basic Information
| Provider Information | |||||||||
| NPI: | 1366830432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRADMAN | ||||||||
| FirstName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1710 W 3RD ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736445160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 N MONTE VISTA ST | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803322323 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2014 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041368366 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 209012356 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.