Provider Demographics
NPI:1922008572
Name:LEWIS-WYATT, NIKI S (PAC)
Entity Type:Individual
Prefix:
First Name:NIKI
Middle Name:S
Last Name:LEWIS-WYATT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:NIKI
Other - Middle Name:S
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:221 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:OK
Mailing Address - Zip Code:73728-2029
Mailing Address - Country:US
Mailing Address - Phone:580-307-6263
Mailing Address - Fax:580-603-8602
Practice Address - Street 1:221 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:OK
Practice Address - Zip Code:73728
Practice Address - Country:US
Practice Address - Phone:580-307-6263
Practice Address - Fax:580-603-8602
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK758363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100132420CMedicaid
OKP00613955Medicare PIN
S42604Medicare UPIN
OK244531102Medicare PIN