Provider Demographics
NPI:1790986826
Name:EDMINSTEN, CHAD STEVEN (ATC, PA-C)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:STEVEN
Last Name:EDMINSTEN
Suffix:
Gender:M
Credentials:ATC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 W TECUMSEH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1810
Mailing Address - Country:US
Mailing Address - Phone:405-360-6764
Mailing Address - Fax:
Practice Address - Street 1:3400 W TECUMSEH RD STE 101
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1810
Practice Address - Country:US
Practice Address - Phone:405-360-6764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAT2332255A2300X
OK2464363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical