Provider Demographics
NPI:1417467762
Name:EDERER, AUSTIN KURT
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:KURT
Last Name:EDERER
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 1:2601 FAWN LILY RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73128-1001
Mailing Address - Country:US
Mailing Address - Phone:405-227-5543
Mailing Address - Fax:
Practice Address - Street 1:205 S ACADEMY RD
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-8727
Practice Address - Country:US
Practice Address - Phone:405-282-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-01
Last Update Date:2017-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant