Provider Demographics
NPI:1154310522
Name:RAY, RICHARD V (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:V
Last Name:RAY
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:WHASC
Mailing Address - Street 2:2200 BERGQUEST DR
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:WHASC
Practice Address - Street 2:2200 BERGQUIST DR
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:770-914-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003915363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant