Provider Demographics
NPI:1578953477
Name:NICASIO, VINCENT JR
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:NICASIO
Suffix:JR
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 1:471 N MARSHALL LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-6216
Mailing Address - Country:US
Mailing Address - Phone:928-388-4453
Mailing Address - Fax:
Practice Address - Street 1:471 N MARSHALL LOOP RD
Practice Address - Street 2:
Practice Address - City:SOMERTON
Practice Address - State:AZ
Practice Address - Zip Code:85350-6216
Practice Address - Country:US
Practice Address - Phone:928-388-4453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist