Provider Demographics
NPI:1427036698
Name:TESSMER, RICHARD CLAY (PAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CLAY
Last Name:TESSMER
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 1:735 NORTH FOREMAN
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301
Mailing Address - Country:US
Mailing Address - Phone:918-256-0193
Mailing Address - Fax:918-256-4140
Practice Address - Street 1:10 SOUTH TREATY ROAD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354
Practice Address - Country:US
Practice Address - Phone:918-542-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1285363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20026230BMedicaid
OK20026230BMedicaid