Provider Demographics
NPI:1689142002
Name:VICK, TONY (PMD, CER AT)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:VICK
Suffix:
Gender:M
Credentials:PMD, CER AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13326 SEA BREEZE LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-9203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5266
Practice Address - Country:US
Practice Address - Phone:352-253-3857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMD18799146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic