Provider Demographics
NPI:1699308551
Name:WARNER, EDWIN LEROY JR
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:LEROY
Last Name:WARNER
Suffix:JR
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 1:626 E SYMMES ST APT B
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-5470
Mailing Address - Country:US
Mailing Address - Phone:405-204-6046
Mailing Address - Fax:
Practice Address - Street 1:220 S BARNWELL ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-4507
Practice Address - Country:US
Practice Address - Phone:619-246-0561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS083207059OtherDRIVER LICENSE