Provider Demographics
NPI:1316401870
Name:EDGMON, WILLIAM DALE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DALE
Last Name:EDGMON
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 6 BOX 840
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-8703
Mailing Address - Country:US
Mailing Address - Phone:918-696-8800
Mailing Address - Fax:918-696-8840
Practice Address - Street 1:RR 6 BOX 840
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-8703
Practice Address - Country:US
Practice Address - Phone:918-696-8800
Practice Address - Fax:918-696-8840
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK121570163WI0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0600XNursing Service ProvidersRegistered NurseInfection Control