Provider Demographics
NPI:1760437875
Name:WHALEY, LANCE DEWEY (MD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:DEWEY
Last Name:WHALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MS
Other - First Name:CAROLYN
Other - Middle Name:E
Other - Last Name:GASKILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:116 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:MS
Mailing Address - Zip Code:38666-1721
Mailing Address - Country:US
Mailing Address - Phone:662-487-1605
Mailing Address - Fax:662-487-9068
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SARDIS
Practice Address - State:MS
Practice Address - Zip Code:38666-1721
Practice Address - Country:US
Practice Address - Phone:662-487-1605
Practice Address - Fax:662-487-9068
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB90667Medicare UPIN