Provider Demographics
NPI:1548204589
Name:COLEMAN, LANCE WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:WAYNE
Last Name:COLEMAN
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 1:520 S EAGLE RD
Mailing Address - Street 2:#1223
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6308
Mailing Address - Country:US
Mailing Address - Phone:208-888-4368
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:#1223
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6308
Practice Address - Country:US
Practice Address - Phone:208-888-4368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7160207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
G54719Medicare UPIN
ID1137393Medicare PIN