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General NPI Number Information
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NPI Number | 1174594808
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Entity Type | Individual
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Provider Name | TIMOTHY M RAYCOB PAC
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Gender | Male
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Dates
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Enumeration Date | 01/31/2006
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Last Update Date | 08/01/2012
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Provider Practice Location Address
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Address Line | 411 S KEELER, AB-02-234C PHILLIPS 66 HEALTH SERVICES
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City | BARTLESVILLE
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State | OK
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Zip | 74003-6670
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Country | US
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Telephone | 918-661-6811
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Fax | 918-977-8005
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Provider Business Mailing Address
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Address Line | 402452 W 2200 RD
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City | BARTLESVILLE
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State | OK
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Zip | 74006-0448
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Country | US
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Telephone | 832-477-0379
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA04283
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2136
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License Number State | OK
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