Provider Demographics
NPI:1184668998
Name:FANNING, KYLE (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FANNING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-793-1188
Mailing Address - Fax:405-793-0492
Practice Address - Street 1:1401 SW 34TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3059
Practice Address - Country:US
Practice Address - Phone:405-793-1188
Practice Address - Fax:405-793-0492
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100197770BMedicaid
OK100197770CMedicaid
OK249434902Medicare PIN
OK100197770CMedicaid
OKB68906Medicare UPIN