Provider Demographics
NPI:1063032001
Name:LANCE, MICHAEL DALE II (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DALE
Last Name:LANCE
Suffix:II
Gender:M
Credentials:CRNA
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Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:502-587-4784
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-852-1735
Practice Address - Fax:502-852-6056
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3014694367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100679990Medicaid
IN300040935Medicaid