Provider Demographics
NPI:1174594808
Name:RAYCOB, TIMOTHY M (PAC)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:M
Last Name:RAYCOB
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 1:402452 W 2200 RD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-0448
Mailing Address - Country:US
Mailing Address - Phone:832-477-0379
Mailing Address - Fax:
Practice Address - Street 1:411 S KEELER, AB-02-234C
Practice Address - Street 2:PHILLIPS 66 HEALTH SERVICES
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-6670
Practice Address - Country:US
Practice Address - Phone:918-661-6811
Practice Address - Fax:918-977-8005
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04283363A00000X
OK2136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant