MEDICARE: G ANDREW MCNICKLE 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	207Q00000X	Family Medicine Physician	04-16812	KS

General Provider Information

NPI Number	:	1972548733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	G ANDREW MCNICKLE MD

Provider Business Mailing Address
First Line	:	1131 S CLIFTON AVE
Second Line	:	SUITE B
City	:	WICHITA
State	:	KS
Zip	:	67218-2955
Country	:	US
Telephone Number	:	316-462-1040
Fax Number	:	316-462-1042

Provider Business Practice Location Address
First Line	:	1131 S CLIFTON AVE
Second Line	:	SUITE B
City	:	WICHITA
State	:	KS
Zip	:	67218-2955
Country	:	US
Telephone Number	:	316-462-1040
Fax Number	:	316-462-1042

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

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	01/21/2015

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