Provider Demographics
NPI:1043446008
Name:SPAFFORD, RALPH DOUGLAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:DOUGLAS
Last Name:SPAFFORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 TALON DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:916 TALON DR
Practice Address - Street 2:SUITE 102
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1848
Practice Address - Country:US
Practice Address - Phone:618-628-8211
Practice Address - Fax:618-628-0883
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117199363AM0700X
IL385000318363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1811940893OtherTRICARE
IL1811940893OtherAETNA
IL1811940893OtherHEALTHLINK
IL1811940893OtherCIGNA
IL1811940893OtherUHC
IL1811940893OtherBCBS
IL207465Medicare PIN