Provider Demographics
NPI:1104934116
Name:VICKREY, CHARLES ALAN (FNP)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALAN
Last Name:VICKREY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 N PIEDRAS ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-4210
Mailing Address - Country:US
Mailing Address - Phone:915-564-6100
Mailing Address - Fax:915-564-7951
Practice Address - Street 1:5001 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-4210
Practice Address - Country:US
Practice Address - Phone:915-564-6100
Practice Address - Fax:915-564-7951
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX691712163W00000X
NMR66418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty