Provider Demographics
NPI:1760494611
Name:HARDWIG, LANCE E (PA,)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:E
Last Name:HARDWIG
Suffix:
Gender:M
Credentials:PA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 13TH AVE E
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3675
Mailing Address - Country:US
Mailing Address - Phone:218-263-7540
Mailing Address - Fax:866-732-0699
Practice Address - Street 1:13071 NETT LAKE RD.
Practice Address - Street 2:
Practice Address - City:NETT LAKE
Practice Address - State:MN
Practice Address - Zip Code:55771
Practice Address - Country:US
Practice Address - Phone:218-757-3295
Practice Address - Fax:218-757-0222
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
30109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN63G36HAOtherBCBS
MN63G36HAOtherBCBS
MNR04645Medicare UPIN