Provider Demographics
NPI:1023020641
Name:RICKNER, KYLE W (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:W
Last Name:RICKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 COMMONS CR
Mailing Address - Street 2:SUITE A
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-9518
Mailing Address - Country:US
Mailing Address - Phone:405-265-2778
Mailing Address - Fax:405-494-7274
Practice Address - Street 1:11 PALM AVE
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-5645
Practice Address - Country:US
Practice Address - Phone:405-350-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100256110AMedicaid
OK100256110AMedicaid
OKG98721Medicare UPIN