Provider Demographics
NPI:1558358655
Name:ELDER, BRENDA (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:ELDER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:ELDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:23778 S MITCHELL LANE
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434
Mailing Address - Country:US
Mailing Address - Phone:918-478-4394
Mailing Address - Fax:
Practice Address - Street 1:1001 SO. 41ST ST. EAST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1404
Practice Address - Country:US
Practice Address - Phone:918-687-0201
Practice Address - Fax:918-687-0665
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0051899363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1751899Medicaid
OK8EZ10WMedicare UPIN
OK8EZ11WMedicare UPIN
OK8EZ08WMedicare UPIN
OK8EZ12WMedicare UPIN
OK1751899Medicaid