Provider Demographics
NPI:1699335331
Name:VINCENT, MICHAEL THOMAS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:VINCENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 E DRAKE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-4907
Mailing Address - Country:US
Mailing Address - Phone:928-890-7759
Mailing Address - Fax:
Practice Address - Street 1:1305 N MARTIN AVENUE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85721-0001
Practice Address - Country:US
Practice Address - Phone:520-626-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD00762266390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program