Provider Demographics
NPI:1063459790
Name:GRAMMONT, LANCE A (DO)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:A
Last Name:GRAMMONT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 N GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7863
Mailing Address - Country:US
Mailing Address - Phone:920-830-6877
Mailing Address - Fax:
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-830-6877
Practice Address - Fax:920-454-7013
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI37582500Medicaid
WI37582500Medicaid
WI062271018Medicare PIN