Provider Demographics
NPI:1073062956
Name:VICKERS, KENDEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KENDEL
Middle Name:
Last Name:VICKERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1990
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34423-1990
Mailing Address - Country:US
Mailing Address - Phone:352-746-4176
Mailing Address - Fax:
Practice Address - Street 1:950 N AVALON WAY
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-6004
Practice Address - Country:US
Practice Address - Phone:352-746-2663
Practice Address - Fax:352-746-6907
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPAT9109925OtherSTATE LICENSE