Provider Demographics
NPI:1346238755
Name:SISCO, LANCE THAYER (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:THAYER
Last Name:SISCO
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 5418
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27204-5418
Mailing Address - Country:US
Mailing Address - Phone:336-625-2333
Mailing Address - Fax:336-625-5511
Practice Address - Street 1:138A DUBLIN SQUARE RD
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-8627
Practice Address - Country:US
Practice Address - Phone:336-626-2688
Practice Address - Fax:336-626-4100
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33307207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891356AMedicaid
NCE93398Medicare UPIN
NC2016108AMedicare PIN