Provider Demographics
NPI:1891429148
Name:RUCKER, SIDRA E
Entity Type:Individual
Prefix:
First Name:SIDRA
Middle Name:E
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10910 N PENN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-7610
Mailing Address - Country:US
Mailing Address - Phone:405-906-9338
Mailing Address - Fax:
Practice Address - Street 1:10910 N PENN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7610
Practice Address - Country:US
Practice Address - Phone:405-906-9338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty