Provider Demographics
NPI:1487632667
Name:VICK, TANNER JAMES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TANNER
Middle Name:JAMES
Last Name:VICK
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 3360
Mailing Address - Street 2:PROVIDENCE HEALTH & SERVICES
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:1330 ROCKEFELLER AVE
Practice Address - Street 2:STE 520
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1684
Practice Address - Country:US
Practice Address - Phone:425-297-5200
Practice Address - Fax:425-297-5210
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004747363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA191975OtherL&I PROVIDER NUMBER
WA8412868Medicaid
WA8412868Medicaid
WAQ31992Medicare UPIN
WA191975OtherL&I PROVIDER NUMBER