Healthcare Provider Details

I. General information

NPI: 1922008572
Provider Name (Legal Business Name): NIKI S LEWIS-WYATT PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKI S LEWIS PAC

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S GRAND AVE
CHEROKEE OK
73728-2029
US

IV. Provider business mailing address

221 S GRAND AVE
CHEROKEE OK
73728-2029
US

V. Phone/Fax

Practice location:
  • Phone: 580-307-6263
  • Fax: 580-603-8602
Mailing address:
  • Phone: 580-307-6263
  • Fax: 580-603-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number758
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: