Provider Demographics
NPI:1619937703
Name:LANTZ, BRYAN T (PAC)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:T
Last Name:LANTZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743
Mailing Address - Country:US
Mailing Address - Phone:603-542-7666
Mailing Address - Fax:603-542-9312
Practice Address - Street 1:241 ELM ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743
Practice Address - Country:US
Practice Address - Phone:603-542-7666
Practice Address - Fax:603-542-9312
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0486P363A00000X
VT0550030669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30332565Medicaid
NH421539118OtherUNITED HEALTHCARE
NH01Y004009NH01OtherANTHEM BC/BS OF NEW HAMPSHIRE
VT0AP2011Medicaid
VT710024OtherMVP
NHF75854OtherHARVARD PILGRIM
VT59775OtherBCVT
NH1387569OtherCIGNA HEALTHCARE
NH2972483OtherAETNA
VT710024OtherMVP
P98763Medicare UPIN
NHAP2011Medicare PIN