Provider Demographics
NPI:1598209694
Name:FORD, VINCENT EDWARD (CRNA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:EDWARD
Last Name:FORD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9508 S 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-7746
Mailing Address - Country:US
Mailing Address - Phone:919-923-3584
Mailing Address - Fax:
Practice Address - Street 1:18701 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7100
Practice Address - Country:US
Practice Address - Phone:623-561-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001250252390200000X
AZ256475367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program