MEDICARE: DR. OSEKPAMEN WICKLIFFE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	38402	OK

General Provider Information

NPI Number	:	1407341142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OSEKPAMEN WICKLIFFE MD

Provider Business Mailing Address
First Line	:	5310 E 31ST ST STE LL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-5013
Country	:	US
Telephone Number	:	918-236-4000
Fax Number	:	918-236-4001

Provider Business Practice Location Address
First Line	:	5310 E 31ST ST STE LL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-5013
Country	:	US
Telephone Number	:	918-236-4000
Fax Number	:	918-236-4001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	06/30/2023

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