Healthcare Provider Details

I. General information

NPI: 1982683322
Provider Name (Legal Business Name): PETER MICHAEL VINCENT D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12911 120TH AVE NE STE C50
KIRKLAND WA
98034-3080
US

IV. Provider business mailing address

12911 120TH AVE NE STE C50
KIRKLAND WA
98034-3080
US

V. Phone/Fax

Practice location:
  • Phone: 425-899-3234
  • Fax: 425-899-3235
Mailing address:
  • Phone: 425-899-3234
  • Fax: 425-899-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO000000750
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPO00000750
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: