Provider Demographics
NPI:1578578183
Name:VINCENT, TY R (MD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:R
Last Name:VINCENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 BOGARD RD STE 100
Mailing Address - Street 2:BUILDING A
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6563
Mailing Address - Country:US
Mailing Address - Phone:907-352-6200
Mailing Address - Fax:907-373-0725
Practice Address - Street 1:1700 BOGARD RD STE 100
Practice Address - Street 2:BUILDING A
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6563
Practice Address - Country:US
Practice Address - Phone:907-352-6200
Practice Address - Fax:907-373-0725
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD61582Medicaid
AK160222Medicare ID - Type Unspecified
AKI31421Medicare UPIN