Provider Demographics
NPI:1780791434
Name:VICKERS, THOMAS A (CRNA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:VICKERS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 172104
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-2104
Mailing Address - Country:US
Mailing Address - Phone:901-682-6828
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-682-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN8876367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN117372OtherBETTER HEALTH
430051284OtherRR MEDICARE
TN11683OtherTLC
MS00116187OtherMS MEDICAID
2040382OtherUHC
3028386OtherB/C
430051284OtherRR MEDICARE