Provider Demographics
NPI:1275198368
Name:ABERNATHY, LANT JARVIS (DPM)
Entity Type:Individual
Prefix:
First Name:LANT
Middle Name:JARVIS
Last Name:ABERNATHY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93483-0759
Mailing Address - Country:US
Mailing Address - Phone:805-712-6867
Mailing Address - Fax:888-851-4755
Practice Address - Street 1:862 MEINECKE AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-3703
Practice Address - Country:US
Practice Address - Phone:805-540-5770
Practice Address - Fax:888-851-4755
Is Sole Proprietor?:No
Enumeration Date:2019-05-05
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAE5955213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE5955OtherCA MEDICAL LICENSE
CAE2424420OtherDRIVERS LISCENSE