Healthcare Provider Details

I. General information

NPI: 1760774616
Provider Name (Legal Business Name): NICHOLAS G VANCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 PHYSICIANS DRIVE
JACKSON TN
38305-2070
US

IV. Provider business mailing address

24 PHYSICIANS DRIVE
JACKSON TN
38305-2070
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-9825
  • Fax: 731-668-6757
Mailing address:
  • Phone: 731-661-9825
  • Fax: 731-668-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD0000056124
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number56124
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101259929
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0040945
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: