Provider Demographics
NPI:1114925245
Name:PEEVY, ROBERT E (PAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:PEEVY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15951 LITTLE AXE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-9088
Mailing Address - Country:US
Mailing Address - Phone:405-447-0300
Mailing Address - Fax:405-701-7631
Practice Address - Street 1:2029 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9005
Practice Address - Country:US
Practice Address - Phone:405-878-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00731972OtherMEDICARE RAILROAD
P00731972OtherMEDICARE RAILROAD