Healthcare Provider Details

I. General information

NPI: 1952978330
Provider Name (Legal Business Name): KRISTIN VICKERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2021
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6251 E VIRGINIA BEACH BLVD STE 200
NORFOLK VA
23502-2824
US

IV. Provider business mailing address

6350 CENTER DR STE 200
NORFOLK VA
23502-4107
US

V. Phone/Fax

Practice location:
  • Phone: 757-466-8683
  • Fax: 757-466-8892
Mailing address:
  • Phone: 757-213-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110008319
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: