Provider Demographics
NPI:1417520149
Name:HARDIN, EDIE
Entity Type:Individual
Prefix:
First Name:EDIE
Middle Name:
Last Name:HARDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12531 E MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4152
Mailing Address - Country:US
Mailing Address - Phone:316-644-5295
Mailing Address - Fax:
Practice Address - Street 1:880 W CENTRAL RD STE 4500
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2388
Practice Address - Country:US
Practice Address - Phone:847-398-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085008661OtherSTATE LICENSE