Healthcare Provider Details

I. General information

NPI: 1457565988
Provider Name (Legal Business Name): NIKKI ZYBACH P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SW 89TH ST
OKLAHOMA CITY OK
73139-8503
US

IV. Provider business mailing address

210 SW 89TH ST
OKLAHOMA CITY OK
73139-8532
US

V. Phone/Fax

Practice location:
  • Phone: 405-631-0663
  • Fax: 405-631-7047
Mailing address:
  • Phone: 405-631-0663
  • Fax: 405-631-7047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1104
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: