Provider Demographics
NPI:1700264777
Name:VICKERS, RYAN TAIT (PA-C, MMS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TAIT
Last Name:VICKERS
Suffix:
Gender:M
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1201
Mailing Address - Country:US
Mailing Address - Phone:805-955-6000
Mailing Address - Fax:
Practice Address - Street 1:2975 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1201
Practice Address - Country:US
Practice Address - Phone:805-955-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52475363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant