Provider Demographics
NPI:1124602347
Name:EDDLEMAN, DEANNA DAWN (CST, CSFA)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:DAWN
Last Name:EDDLEMAN
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13901 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3771
Mailing Address - Country:US
Mailing Address - Phone:918-232-8433
Mailing Address - Fax:918-970-4314
Practice Address - Street 1:13901 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-3771
Practice Address - Country:US
Practice Address - Phone:918-232-8433
Practice Address - Fax:918-970-4314
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK149132246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant