Provider Demographics
NPI:1184287849
Name:PROCTOR, PERRY JAKE (DO)
Entity type:Individual
Prefix:
First Name:PERRY
Middle Name:JAKE
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 E ROSS ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0545
Mailing Address - Country:US
Mailing Address - Phone:539-234-1000
Mailing Address - Fax:
Practice Address - Street 1:245 WINDWARD WAY STE 101
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3385
Practice Address - Country:US
Practice Address - Phone:406-756-8488
Practice Address - Fax:406-758-3234
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTMED-PHYS-LIC-110556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program