Provider Demographics
NPI:1962025585
Name:VINCENT, ZACHARY J
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:J
Last Name:VINCENT
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 1:1102 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3503
Mailing Address - Country:US
Mailing Address - Phone:417-347-6612
Mailing Address - Fax:
Practice Address - Street 1:113 W HICKORY ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-1705
Practice Address - Country:US
Practice Address - Phone:417-451-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010160207P00000X
390200000X
MO2021043447207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program