Provider Demographics
NPI:1437128857
Name:VICKERS, MITCHAEL LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:MITCHAEL
Middle Name:LEE
Last Name:VICKERS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1552
Mailing Address - Country:US
Mailing Address - Phone:678-763-5144
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL BLVD
Practice Address - Street 2:SUITE 480
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4975
Practice Address - Country:US
Practice Address - Phone:678-762-0676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN141647367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00232387OtherRR MEDICARE
GA000806242MMedicaid
P00232387OtherRR MEDICARE
GA43BBBJJMedicare ID - Type Unspecified