Provider Demographics
NPI:1700923414
Name:KALKBRENNER BURR, EDITH ANN (PA)
Entity Type:Individual
Prefix:MS
First Name:EDITH
Middle Name:ANN
Last Name:KALKBRENNER BURR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:EDITH
Other - Middle Name:ANN
Other - Last Name:BURR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1921 STONECIPHER DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3439
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:580-421-6283
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-421-4570
Practice Address - Fax:580-421-6283
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1700923414Medicaid
OK249713001Medicare PIN
OK1700923414Medicaid