Healthcare Provider Details

I. General information

NPI: 1487077970
Provider Name (Legal Business Name): ROY WYCKOFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 MABEL C FRY BLVD
YUKON OK
73099-2810
US

IV. Provider business mailing address

724 MABEL C FRY BLVD
YUKON OK
73099-2810
US

V. Phone/Fax

Practice location:
  • Phone: 405-473-2928
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: