Provider Demographics
NPI:1578222188
Name:PORT, LANCE WESLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:WESLEY
Last Name:PORT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13613 N MANNING LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5173
Mailing Address - Country:US
Mailing Address - Phone:208-479-7678
Mailing Address - Fax:
Practice Address - Street 1:103 S DAISY ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467
Practice Address - Country:US
Practice Address - Phone:208-756-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical