Provider Demographics
NPI:1215334560
Name:PROCTOR, E JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:E
Middle Name:JEAN
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EULA
Other - Middle Name:JEAN
Other - Last Name:IRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:940 E 3RD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3200
Mailing Address - Country:US
Mailing Address - Phone:307-439-2031
Mailing Address - Fax:307-439-2033
Practice Address - Street 1:940 E 3RD ST STE 103
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3200
Practice Address - Country:US
Practice Address - Phone:307-439-2031
Practice Address - Fax:307-439-2033
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-02
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant