Provider Demographics
NPI:1679844088
Name:VINCENT, JOHN ENOCH (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ENOCH
Last Name:VINCENT
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 1:100 WOMANS WAY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-5100
Mailing Address - Country:US
Mailing Address - Phone:225-924-8149
Mailing Address - Fax:225-293-1807
Practice Address - Street 1:8212 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3421
Practice Address - Country:US
Practice Address - Phone:225-769-4403
Practice Address - Fax:225-769-3842
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATAP002736367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered