Provider Demographics
NPI:1558394288
Name:VICKERS, LAURICE SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:LAURICE
Middle Name:SAMUEL
Last Name:VICKERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L.
Other - Middle Name:SAMUEL
Other - Last Name:VICKERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 34245
Mailing Address - Street 2:PSIP
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1245
Mailing Address - Country:US
Mailing Address - Phone:206-622-7747
Mailing Address - Fax:206-467-1470
Practice Address - Street 1:1001 KLICKITAT WAY SW
Practice Address - Street 2:SUITE 205 PSIP
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134
Practice Address - Country:US
Practice Address - Phone:206-622-7747
Practice Address - Fax:206-467-1470
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA13323207ZP0102X
OR14782207ZP0102X
AK5586207ZP0102X
CAC42192207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology