Provider Demographics
NPI:1902060833
Name:KISICKI, DANIEL RYAN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RYAN
Last Name:KISICKI
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 1:1950 BLUEGRASS CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7323
Mailing Address - Country:US
Mailing Address - Phone:307-778-2577
Mailing Address - Fax:
Practice Address - Street 1:4017 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-635-2562
Practice Address - Fax:307-638-2074
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092823207Q00000X
WY9010A207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1902060833Medicaid