Basic Information
| Provider Information | |||||||||
| NPI: | 1427036698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TESSMER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | CLAY | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 735 NORTH FOREMAN | ||||||||
| Address2: | |||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182560193 | ||||||||
| FaxNumber: | 9182564140 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 SOUTH TREATY ROAD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185426644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1285 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 20026230B | 05 | OK | MEDICAID |