1821399809 NPI number — VICKIE PAYNE PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821399809 NPI number — VICKIE PAYNE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYNE
Provider First Name:
VICKIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821399809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
367 S GULPH RD
Provider Second Line Business Mailing Address:
ATN :IPM CREDENTIALING
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-3121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-680-1900
Provider Business Mailing Address Fax Number:
806-513-6791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7200 SW 45TH AVE UNIT 14
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79109-5084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-680-1900
Provider Business Practice Location Address Fax Number:
806-513-6791
Provider Enumeration Date:
11/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA06985 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 282515004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1L5087 . This is a "PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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