Provider Demographics
NPI:1417987173
Name:VANCE, OLIN N (DO)
Entity Type:Individual
Prefix:
First Name:OLIN
Middle Name:N
Last Name:VANCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 E LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-6124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BANNER MESA MEDICAL CENTER
Practice Address - Street 2:1010 N. COUNTRY CLUB DRIVE
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3309
Practice Address - Country:US
Practice Address - Phone:480-834-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4073207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH95602Medicare UPIN
AZ83136Medicare ID - Type Unspecified