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General NPI Number Information
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NPI Number | 1437128857
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Entity Type | Individual
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Provider Name | MITCHAEL LEE VICKERS CRNA
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Gender | Male
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Dates
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Enumeration Date | 03/16/2006
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Last Update Date | 11/18/2010
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Provider Practice Location Address
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Address Line | 2500 HOSPITAL BLVD SUITE 480
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City | ROSWELL
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State | GA
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Zip | 30076-4975
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Country | US
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Telephone | 678-762-0676
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Fax |
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Provider Business Mailing Address
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Address Line | 1870 MAYFIELD RD
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City | ALPHARETTA
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State | GA
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Zip | 30009-1552
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Country | US
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Telephone | 678-763-5144
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RN141647
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License Number State | GA
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