Healthcare Provider Details

I. General information

NPI: 1780791434
Provider Name (Legal Business Name): THOMAS A VICKERS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 PARK AVE SUITE 406
MEMPHIS TN
38119-5202
US

IV. Provider business mailing address

PO BOX 172104
MEMPHIS TN
38187-2104
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-6282
  • Fax:
Mailing address:
  • Phone: 901-682-6828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN8876
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: