Provider Demographics
NPI:1164421434
Name:DALEY, ROBERTA L (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:L
Last Name:DALEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:L
Other - Last Name:DALEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:OK
Mailing Address - Zip Code:73834-0010
Mailing Address - Country:US
Mailing Address - Phone:580-735-2506
Mailing Address - Fax:580-735-2728
Practice Address - Street 1:1001 HWY 64 N
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:OK
Practice Address - Zip Code:73834-0010
Practice Address - Country:US
Practice Address - Phone:580-735-2506
Practice Address - Fax:580-735-2728
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1207363A00000X
OK1207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP61691Medicare UPIN