Basic Information
| Provider Information | |||||||||
| NPI: | 1306232491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDORE | ||||||||
| FirstName: | HAIDEN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E STE 400 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
| FaxNumber: | 2293536060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 US HIGHWAY 41 N | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317942749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293914100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2015 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | RN210517 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.