Provider Demographics
NPI:1376544874
Name:VINCENT, PAMELA L (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:VINCENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 N UNIVERSITY AVE # 224
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4405
Mailing Address - Country:US
Mailing Address - Phone:801-885-2303
Mailing Address - Fax:801-437-3273
Practice Address - Street 1:451 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-2927
Practice Address - Country:US
Practice Address - Phone:714-527-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188338-12052084A0401X
WI29118-202084A0401X, 2084N0400X
CAG1458522084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057437Medicare ID - Type Unspecified
UTE44021Medicare UPIN