Basic Information
| Provider Information | |||||||||
| NPI: | 1861482887 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 S RENAISSANCE BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444978 | ||||||||
| FaxNumber: | 4058440562 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 S RENAISSANCE BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444978 | ||||||||
| FaxNumber: | 4058440562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 10/14/2013 | ||||||||
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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 | 363AS0400X | 821 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 100138410B | 05 | OK | MEDICAID |