Provider Demographics
NPI:1932694346
Name:VINCENT, ELIJAH SAMUEL (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:SAMUEL
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 1:17118 SILLS DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3494
Mailing Address - Country:US
Mailing Address - Phone:225-939-1038
Mailing Address - Fax:
Practice Address - Street 1:601 W LEOTA ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6525
Practice Address - Country:US
Practice Address - Phone:308-568-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101500367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered