Provider Demographics
NPI:1609144435
Name:VANTY, LAWRENCE JOSEPH JR (PA)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:JOSEPH
Last Name:VANTY
Suffix:JR
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-344-3512
Mailing Address - Fax:208-344-3512
Practice Address - Street 1:300 S 23RD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-9100
Practice Address - Country:US
Practice Address - Phone:208-344-3512
Practice Address - Fax:208-344-4898
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-953363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1609144435Medicaid