Provider Demographics
NPI:1134591621
Name:VICKREY, ALISA (PA-C)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:VICKREY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 EAST ST STE 200
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0801
Mailing Address - Country:US
Mailing Address - Phone:530-605-4260
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:1355 EAST ST STE 200
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0801
Practice Address - Country:US
Practice Address - Phone:530-605-4260
Practice Address - Fax:707-826-8638
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK103678363A00000X
CA56745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant