Provider Demographics
NPI:1396757332
Name:FRIESEN, RICKY W (MD)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:W
Last Name:FRIESEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 W CENTRAL AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-9503
Mailing Address - Country:US
Mailing Address - Phone:316-722-6260
Mailing Address - Fax:316-721-8307
Practice Address - Street 1:8200 W CENTRAL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-9503
Practice Address - Country:US
Practice Address - Phone:316-722-6260
Practice Address - Fax:316-721-8307
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0421902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4652450OtherAETNA
KS102529OtherBLUE CROSS BLUE SHIELD
KS1433OtherPREFERRED HEALTH SYSTEMS
KSE96846Medicare UPIN
KS102529Medicare ID - Type Unspecified