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General NPI Number Information
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NPI Number | 1720010416
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Entity Type | Individual
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Provider Name | MARCIA JEAN RICKETSON P.A.C.
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Gender | Female
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 06/17/2009
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Provider Practice Location Address
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Address Line | 216 NE 12TH ST
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City | MOORE
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State | OK
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Zip | 73160-5830
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Country | US
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Telephone | 405-794-2530
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Fax | 866-371-6223
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Provider Business Mailing Address
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Address Line | 2829 CHAUCER DR
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City | OKLAHOMA CITY
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State | OK
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Zip | 73120-2804
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Country | US
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Telephone | 405-496-8059
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 710
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License Number State | OK
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