Healthcare Provider Details

I. General information

NPI: 1205502994
Provider Name (Legal Business Name): NICKOLAS LEE SITTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2021
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 KLABZUBA AVE
PRAGUE OK
74864-4900
US

IV. Provider business mailing address

42711 CRIMSON LN
SHAWNEE OK
74804-9371
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-2295
  • Fax:
Mailing address:
  • Phone: 405-432-7273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5202
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: