Provider Demographics
NPI:1558465898
Name:PROCTOR, LANCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:A
Last Name:PROCTOR
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 1:204 MCCOLLUM DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5151
Mailing Address - Country:US
Mailing Address - Phone:307-745-6065
Mailing Address - Fax:307-745-4936
Practice Address - Street 1:255 N 30TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072
Practice Address - Country:US
Practice Address - Phone:307-742-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6560A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116187300Medicaid
WYW308743Medicare PIN
E69071Medicare UPIN