Provider Demographics
NPI:1922770437
Name:SISCO, DANIEL WAYNE
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WAYNE
Last Name:SISCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OH
Mailing Address - Zip Code:74107
Mailing Address - Country:US
Mailing Address - Phone:918-671-3987
Mailing Address - Fax:
Practice Address - Street 1:1111 W 17TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107
Practice Address - Country:US
Practice Address - Phone:918-671-3987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-03
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program