Provider Demographics
NPI:1497574040
Name:VICENTE ENCARANCION, WAGNER
Entity type:Individual
Prefix:
First Name:WAGNER
Middle Name:
Last Name:VICENTE ENCARANCION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:JACKSON VICENTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5349 DUSHORE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-8831
Mailing Address - Country:US
Mailing Address - Phone:937-727-3455
Mailing Address - Fax:
Practice Address - Street 1:5349 DUSHORE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-8831
Practice Address - Country:US
Practice Address - Phone:937-727-3455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker