MEDICARE: SIDRA E RUCKER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	332BC3200X	Customized Equipment (DME)
2	174400000X	Specialist
3	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1891429148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDRA E RUCKER

Provider Business Mailing Address
First Line	:	10910 N PENN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7610
Country	:	US
Telephone Number	:	405-906-9338
Fax Number	:

Provider Business Practice Location Address
First Line	:	10910 N PENN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7610
Country	:	US
Telephone Number	:	405-906-9338
Fax Number	:

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

Provider Enumeration Date	:	07/12/2022
Last Update Date	:	07/12/2022

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Directions to “ SIDRA E RUCKER ” Practice Location

Language	Start Address	Practice Location

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