Provider Demographics
NPI:1780753681
Name:VICKERS, CHAD RANDAL (PMHNP)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:RANDAL
Last Name:VICKERS
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 COLORADO STREET EAST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107
Mailing Address - Country:US
Mailing Address - Phone:651-489-7740
Mailing Address - Fax:651-489-6458
Practice Address - Street 1:135 COLORADO STREET EAST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107
Practice Address - Country:US
Practice Address - Phone:651-489-7740
Practice Address - Fax:651-489-6458
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX706002363LF0000X, 363LP0808X
DEL8-0000171363LP0808X
MN6371363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200101760AMedicaid
TXP01078815OtherRAILROAD MEDICARE
MN1780753681Medicaid
TX182997003Medicaid
TX868N62OtherBCBS
TX182997001Medicaid
TXTXB143671Medicare PIN