Healthcare Provider Details

I. General information

NPI: 1538042957
Provider Name (Legal Business Name): BARON EDMONSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR, WRIGHT-PATTERSON AFB,
APO AA
45433
US

IV. Provider business mailing address

5050 CONERSTONE N BLVD APT 2409
CENTERVILLE OH
45440
US

V. Phone/Fax

Practice location:
  • Phone: 937-731-3880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number14235425-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: