Provider Demographics
NPI:1487683934
Name:VINCENT, THOMAS MARVIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARVIN
Last Name:VINCENT
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 1:4815 N ASSEMBLY ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6185
Mailing Address - Country:US
Mailing Address - Phone:509-434-7010
Mailing Address - Fax:509-434-7131
Practice Address - Street 1:4815 N ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6185
Practice Address - Country:US
Practice Address - Phone:509-434-7010
Practice Address - Fax:509-434-7131
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003468363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA805491500Medicaid
WA1019968OtherNCCPA CERTIFICATE #
WAS92088Medicare UPIN
WA1019968OtherNCCPA CERTIFICATE #