Basic Information
| Provider Information | |||||||||
| NPI: | 1427091826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SECOY | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 W IOWA AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057792721 | ||||||||
| FaxNumber: | 4057792310 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 S RUSH STREET | ||||||||
| Address2: | |||||||||
| City: | RUSH SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730820277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804762527 | ||||||||
| FaxNumber: | 5804763707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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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 | 728 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100053660B | 05 | OK | MEDICAID |