Provider Demographics
NPI:1447753314
Name:PROCTOR, VINCENT MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:MICHAEL
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 WEATHERLY DR STE F
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8915
Mailing Address - Country:US
Mailing Address - Phone:931-494-7131
Mailing Address - Fax:
Practice Address - Street 1:775F WEATHERLY DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8942
Practice Address - Country:US
Practice Address - Phone:931-494-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1151163OtherNCCPA
TN4148OtherTN DEPT OF HEALTH
MP6071271OtherDEA