Healthcare Provider Details

I. General information

NPI: 1366830432
Provider Name (Legal Business Name): EDWARD GRADMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2014
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N MONTE VISTA ST
ADA OK
74820-4610
US

IV. Provider business mailing address

1710 W 3RD ST STE 100
ELK CITY OK
73644-5160
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-2323
  • Fax:
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041368366
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209012356
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: