Provider Demographics
NPI:1447077136
Name:EDWARDS, CASEY LANE
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:LANE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24774 S 4090 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-2298
Mailing Address - Country:US
Mailing Address - Phone:918-519-1284
Mailing Address - Fax:
Practice Address - Street 1:24774 S 4090 RD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74019-2298
Practice Address - Country:US
Practice Address - Phone:918-519-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant