Basic Information
| Provider Information | |||||||||
| NPI: | 1427067859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROCTOR | ||||||||
| FirstName: | ERRON | ||||||||
| MiddleName: | CODY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 358 | ||||||||
| Address2: | 527 WEST 3RD ST | ||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809259149 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748491415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809252362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1410 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 200072810A | 05 | OK | MEDICAID |