Provider Demographics
NPI:1760774616
Name:VANCE, NICHOLAS G (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:G
Last Name:VANCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PHYSICIANS DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2070
Mailing Address - Country:US
Mailing Address - Phone:731-661-9825
Mailing Address - Fax:731-668-6757
Practice Address - Street 1:24 PHYSICIANS DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2070
Practice Address - Country:US
Practice Address - Phone:731-661-9825
Practice Address - Fax:731-668-6757
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000056124207X00000X
TN56124207X00000X
VA0101259929207X00000X
TX0040945207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031011Medicaid