Provider Demographics
NPI:1164479408
Name:FAVORITE, GREGORY RAYMOND (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:RAYMOND
Last Name:FAVORITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:103 W MAIN STREET
Mailing Address - City:RINGLING
Mailing Address - State:OK
Mailing Address - Zip Code:73456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:580-662-2085
Practice Address - Street 1:103 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:RINGLING
Practice Address - State:OK
Practice Address - Zip Code:73456
Practice Address - Country:US
Practice Address - Phone:580-662-2078
Practice Address - Fax:580-662-2085
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA00714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R98140Medicare UPIN