Healthcare Provider Details

I. General information

NPI: 1164019345
Provider Name (Legal Business Name): MELINDA ROSE VICKERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10460 N 92ND ST STE 300
SCOTTSDALE AZ
85258-4547
US

IV. Provider business mailing address

10460 N 92ND ST STE 300
SCOTTSDALE AZ
85258-4547
US

V. Phone/Fax

Practice location:
  • Phone: 480-323-1573
  • Fax:
Mailing address:
  • Phone: 480-323-1573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14229
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10929
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: