Provider Demographics
NPI:1003379868
Name:PROCTOR, BRIE (DO)
Entity Type:Individual
Prefix:
First Name:BRIE
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14075 W KILLABREW RD
Mailing Address - Street 2:
Mailing Address - City:HULBERT
Mailing Address - State:OK
Mailing Address - Zip Code:74441-3717
Mailing Address - Country:US
Mailing Address - Phone:405-535-1728
Mailing Address - Fax:
Practice Address - Street 1:160 HERITAGE WAY STE 202
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3127
Practice Address - Country:US
Practice Address - Phone:406-752-8433
Practice Address - Fax:406-756-6768
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTMED-PHYS-LIC-110557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program