Provider Demographics
NPI:1982481529
Name:EDGE, ROLAND MARCUS
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:MARCUS
Last Name:EDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19504 TALAVERA LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9756
Mailing Address - Country:US
Mailing Address - Phone:405-589-6564
Mailing Address - Fax:
Practice Address - Street 1:19504 TALAVERA LN
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-9756
Practice Address - Country:US
Practice Address - Phone:405-589-6564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist