Provider Demographics
NPI:1821399809
Name:PAYNE, VICKIE (PA-C)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
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 1:367 S GULPH RD
Mailing Address - Street 2:ATN :IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:806-680-1900
Mailing Address - Fax:806-513-6791
Practice Address - Street 1:7200 SW 45TH AVE UNIT 14
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-5084
Practice Address - Country:US
Practice Address - Phone:806-680-1900
Practice Address - Fax:806-513-6791
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282515004Medicaid
TX1L5087OtherPTAN
TXTXB132000Medicare PIN
TXTXB131999Medicare PIN
TXTXB131998Medicare PIN