Provider Demographics
NPI:1205502994
Name:SITTER, NICKOLAS LEE
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:LEE
Last Name:SITTER
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 1:42711 CRIMSON LN
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-9371
Mailing Address - Country:US
Mailing Address - Phone:405-432-7273
Mailing Address - Fax:
Practice Address - Street 1:1322 KLABZUBA AVE
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-4900
Practice Address - Country:US
Practice Address - Phone:405-567-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-21
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK5202363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program