Provider Demographics
NPI:1578542627
Name:PROCTOR, JOSEPH E (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:E
Last Name:PROCTOR
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 1:2551 BOGGY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-3806
Mailing Address - Country:US
Mailing Address - Phone:407-348-0990
Mailing Address - Fax:
Practice Address - Street 1:2551 BOGGY CREEK RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3806
Practice Address - Country:US
Practice Address - Phone:407-348-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103407363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical