Healthcare Provider Details

I. General information

NPI: 1477178564
Provider Name (Legal Business Name): QUADE VICKERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE
SPRINGFIELD MO
65807-5210
US

IV. Provider business mailing address

PO BOX 9007
SPRINGFIELD MO
65808-9007
US

V. Phone/Fax

Practice location:
  • Phone: 417-875-3846
  • Fax:
Mailing address:
  • Phone: 417-875-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06200928
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: