Provider Demographics
NPI:1689965485
Name:SIXKILLER, BRYAN WADE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:WADE
Last Name:SIXKILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 SCOTT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:JBPHH
Mailing Address - State:HI
Mailing Address - Zip Code:96853
Mailing Address - Country:US
Mailing Address - Phone:808-448-6160
Mailing Address - Fax:
Practice Address - Street 1:15TH MEDICAL GROUP
Practice Address - Street 2:755 SCOTT CIRCLE
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96853
Practice Address - Country:US
Practice Address - Phone:808-448-6160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2710152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist