Provider Demographics
NPI:1669577474
Name:CALDERON, EDYE A (PAC)
Entity type:Individual
Prefix:
First Name:EDYE
Middle Name:A
Last Name:CALDERON
Suffix:
Gender:F
Credentials:PAC
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 785
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502
Mailing Address - Country:US
Mailing Address - Phone:580-357-9984
Mailing Address - Fax:580-357-3277
Practice Address - Street 1:319 E JOSEPHINE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542
Practice Address - Country:US
Practice Address - Phone:580-335-7545
Practice Address - Fax:580-335-7619
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2868363AM0700X, 363AS0400X
OK1645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK242722104OtherMEDICARE
AZ816176Medicaid
OK200116340AMedicaid
AZZ77628Medicare ID - Type Unspecified
OK242722104OtherMEDICARE