MEDICARE: MS. STEPHANIE KAYE VICKERY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA2265	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14632500	OTHER	NV	CAQH ID
2	PA2265	OTHER	NV	PA NEVADA LIC

General Provider Information

NPI Number	:	1245711357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEPHANIE KAYE VICKERY PA-C

Provider Business Mailing Address
First Line	:	1155 MILL ST MS M14
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89502-1576
Country	:	US
Telephone Number	:	775-982-5262
Fax Number	:	775-982-4196

Provider Business Practice Location Address
First Line	:	3595 US HIGHWAY 50
Second Line	:
City	:	SILVER SPRINGS
State	:	NV
Zip	:	89429-9613
Country	:	US
Telephone Number	:	775-577-2117
Fax Number	:	775-577-2769

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	06/23/2021

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