Basic Information
| Provider Information | |||||||||
| NPI: | 1669577474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALDERON | ||||||||
| FirstName: | EDYE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 785 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803579984 | ||||||||
| FaxNumber: | 5803573277 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 E JOSEPHINE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803357545 | ||||||||
| FaxNumber: | 5803357619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 08/13/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2868 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 2868 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 1645 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 242722104 | 01 | OK | MEDICARE | OTHER | 816176 | 05 | AZ | MEDICAID | 200116340A | 05 | OK | MEDICAID |