Provider Demographics
NPI:1902361413
Name:ETHRIDGE, CAMERON KEITH (APRN)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:KEITH
Last Name:ETHRIDGE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-0777
Mailing Address - Country:US
Mailing Address - Phone:918-290-9216
Mailing Address - Fax:
Practice Address - Street 1:2308B W HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-6729
Practice Address - Country:US
Practice Address - Phone:918-968-4469
Practice Address - Fax:918-987-1622
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK121857363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200829490AMedicaid