Healthcare Provider Details

I. General information

NPI: 1235709148
Provider Name (Legal Business Name): NANA T VINCENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9821 GREENBELT RD
LANHAM MD
20706-2265
US

IV. Provider business mailing address

PO BOX 122
LANHAM MD
20703-0122
US

V. Phone/Fax

Practice location:
  • Phone: 240-424-9615
  • Fax:
Mailing address:
  • Phone: 240-424-9615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberN0001741
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3336N0007X
TaxonomyNuclear Pharmacy
License NumberN0001741
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberN0001741
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207UN0903X
TaxonomyIn Vivo & In Vitro Nuclear Medicine Physician
License NumberN0001741
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberN0001741
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License NumberN0001741
License Number StateMD
# 7
Primary TaxonomyY
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberN0001741
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: