Provider Demographics
NPI:1104828045
Name:NANCE, LARRY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ALLEN
Last Name:NANCE
Suffix:
Gender:M
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:866-775-3551
Mailing Address - Fax:703-365-7702
Practice Address - Street 1:7915 LAKE MANASSAS DRIVE
Practice Address - Street 2:SUTIE 205
Practice Address - City:GAINESVILLE
Practice Address - State:NC
Practice Address - Zip Code:20155-3260
Practice Address - Country:US
Practice Address - Phone:866-755-3551
Practice Address - Fax:703-365-7702
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037658174400000X
NC0101037658207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006213987Medicaid
VA006213987Medicaid