Healthcare Provider Details

I. General information

NPI: 1962025585
Provider Name (Legal Business Name): ZACHARY J VINCENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W HICKORY ST
NEOSHO MO
64850-1705
US

IV. Provider business mailing address

1102 W 32ND ST
JOPLIN MO
64804-3503
US

V. Phone/Fax

Practice location:
  • Phone: 417-451-1234
  • Fax:
Mailing address:
  • Phone: 417-347-6612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number010160
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021043447
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: