Provider Demographics
NPI:1932130150
Name:FALCONER, RALPH (PA-C)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:FALCONER
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 1:610 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-371-2343
Mailing Address - Fax:580-371-3614
Practice Address - Street 1:610 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3245
Practice Address - Country:US
Practice Address - Phone:580-371-2343
Practice Address - Fax:580-371-3614
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK670363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100718060BMedicaid
TX201624803Medicaid
TX414190YMCMMedicare PIN
OK263049ZMALMedicare PIN
OK100718060BMedicaid