Individual
CHAD RANDAL VICKERS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PMHNP
Contact information
Practice address
135 COLORADO STREET EAST, SAINT PAUL, MN 55107
(651) 489-7740
(651) 489-6458
Mailing address
135 COLORADO STREET EAST, SAINT PAUL, MN 55107
(651) 489-7740
(651) 489-6458
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
706002
TX
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
6371
MN
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
706002
TX
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
L8-0000171
DE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1780753681
—
MN
05
—
182997001
—
TX
05
—
182997003
—
TX
05
—
200101760A
—
OK
01
—
868N62
BCBS
TX
01
—
P01078815
RAILROAD MEDICARE
TX
Enumeration date
11/06/2006
Last updated
04/22/2020
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