Provider Demographics
NPI:1437432036
Name:PRIDE, LANCE LINCOLN (PA)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:LINCOLN
Last Name:PRIDE
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 1:5301 E HURON RIVER DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-460
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5355
Practice Address - Country:US
Practice Address - Phone:269-341-7333
Practice Address - Fax:269-341-7371
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006118363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV9406AOtherMEDICARE PTAN
VA14374322036Medicaid
VA10111084POtherSENTARA HEALTH PLANS
VA14374322036OtherTRICARE