Provider Demographics
NPI:1356320436
Name:BORUP, LANCE HAMILTON (DO)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:HAMILTON
Last Name:BORUP
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 1:1202 RUSTIC RDG
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3679
Mailing Address - Country:US
Mailing Address - Phone:417-434-2991
Mailing Address - Fax:
Practice Address - Street 1:525 BRANSON LANDING BLVD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2052
Practice Address - Country:US
Practice Address - Phone:417-875-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05337912085R0202X
OK45872085R0202X
ARE-88602085R0202X
MO20090184312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1356320436Medicaid
KS200614030DMedicaid
MO204512701Medicaid
OK200202290AMedicaid