Provider Demographics
NPI:1174251334
Name:VICKREY, AUSTIN BROCK (PA)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:BROCK
Last Name:VICKREY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5819 JUVENE WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45233-4731
Mailing Address - Country:US
Mailing Address - Phone:513-335-2856
Mailing Address - Fax:
Practice Address - Street 1:5819 JUVENE WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45233-4731
Practice Address - Country:US
Practice Address - Phone:513-335-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA3132363A00000X
OH50.007606RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant