Provider Demographics
NPI:1861482887
Name:CAMPBELL, ERIC J (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S RENAISSANCE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3084
Mailing Address - Country:US
Mailing Address - Phone:405-844-4978
Mailing Address - Fax:405-844-0562
Practice Address - Street 1:1701 S RENAISSANCE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3084
Practice Address - Country:US
Practice Address - Phone:405-844-4978
Practice Address - Fax:405-844-0562
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK821363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100138410BMedicaid
244419704Medicare ID - Type Unspecified
S40562Medicare UPIN