Provider Demographics
NPI:1245890524
Name:VICKERS, CONOR MORAN
Entity type:Individual
Prefix:
First Name:CONOR
Middle Name:MORAN
Last Name:VICKERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E 2ND ST APT 304
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-1706
Mailing Address - Country:US
Mailing Address - Phone:303-319-5980
Mailing Address - Fax:
Practice Address - Street 1:301 E 2ND ST APT 304
Practice Address - Street 2:
Practice Address - City:HUMMELSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17036-1706
Practice Address - Country:US
Practice Address - Phone:303-319-5980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD480075207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program