Provider Demographics
NPI:1912960196
Name:MCCABE, JOHNNY RAY (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:RAY
Last Name:MCCABE
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 1:1 E CLARK BASS BLVD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4209
Mailing Address - Country:US
Mailing Address - Phone:918-421-6960
Mailing Address - Fax:918-421-6094
Practice Address - Street 1:3 E CLARK BASS BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4283
Practice Address - Country:US
Practice Address - Phone:918-421-6960
Practice Address - Fax:918-421-6094
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1324230001OtherPALMETTO DME
OKJ MCCABE PAOtherSTERLING OPTION 1
OKP00090959OtherRR MEDICARE (PALMETTO)
OK200005680BMedicaid
OK200005680COtherSOONER PCP
OKP00090959OtherRR MEDICARE (PALMETTO)