Provider Demographics
NPI:1972548733
Name:MCNICKLE, G ANDREW (MD)
Entity type:Individual
Prefix:
First Name:G
Middle Name:ANDREW
Last Name:MCNICKLE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1131 S CLIFTON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2955
Mailing Address - Country:US
Mailing Address - Phone:316-462-1040
Mailing Address - Fax:316-462-1042
Practice Address - Street 1:1131 S CLIFTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2955
Practice Address - Country:US
Practice Address - Phone:316-462-1040
Practice Address - Fax:316-462-1042
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2015-01-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS04-16812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B91089Medicare UPIN