Provider Demographics
NPI:1427067859
Name:PROCTOR, ERRON CODY (PAC)
Entity type:Individual
Prefix:MR
First Name:ERRON
Middle Name:CODY
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:PAC
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Other - Credentials:
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:527 WEST 3RD ST
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-9149
Practice Address - Street 1:527 W 3RD ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-1415
Practice Address - Country:US
Practice Address - Phone:580-925-3286
Practice Address - Fax:580-925-2362
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1410363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200072810AMedicaid
OK200072810AMedicaid