Provider Demographics
NPI:1407800097
Name:LANCE, CLIFFORD S (PA)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:S
Last Name:LANCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2134
Mailing Address - Country:US
Mailing Address - Phone:541-266-3600
Mailing Address - Fax:541-269-0708
Practice Address - Street 1:2699 N 17TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2134
Practice Address - Country:US
Practice Address - Phone:541-266-3600
Practice Address - Fax:541-269-0708
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
97420A004OtherTRICARE
C105013OtherPACIFIC SOURCE
OR097WCSBVAMedicare ID - Type Unspecified
C105013OtherPACIFIC SOURCE