Provider Demographics
NPI:1043235963
Name:BLACKWELL, VICKI M (PA)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:M
Last Name:BLACKWELL
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:M
Other - Last Name:BURLESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3820 NORTHDALE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1893
Mailing Address - Country:US
Mailing Address - Phone:800-991-6117
Mailing Address - Fax:
Practice Address - Street 1:3657 MADACA LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2048
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9120078363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051553463Medicaid
ALP00010094OtherRR MEDICARE
AL51514981BUROtherBLUE CROSS OF ALABAMA
AL051553463BURMedicare ID - Type UnspecifiedBROOKWOOD OFFICE
ALP00010094OtherRR MEDICARE