Provider Demographics
NPI:1760173405
Name:VINCENT, DANIEL (PTA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:VINCENT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 E FAIRVIEW AVE APT M201
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1837
Mailing Address - Country:US
Mailing Address - Phone:515-249-8881
Mailing Address - Fax:
Practice Address - Street 1:4623 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6764
Practice Address - Country:US
Practice Address - Phone:208-455-4231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-7438208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation