Provider Demographics
NPI:1659783157
Name:NASH, VINCENT MARLON
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:MARLON
Last Name:NASH
Suffix:
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 1:4502 W MELVINA ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2437
Mailing Address - Country:US
Mailing Address - Phone:414-305-9407
Mailing Address - Fax:
Practice Address - Street 1:4502 W MELVINA ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2437
Practice Address - Country:US
Practice Address - Phone:414-305-9407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100037116Medicaid