Provider Demographics
NPI:1801035621
Name:LANTZ, BRAYSON
Entity Type:Individual
Prefix:
First Name:BRAYSON
Middle Name:
Last Name:LANTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 CROWLEY RAYNE HWY
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-8202
Mailing Address - Country:US
Mailing Address - Phone:337-788-6407
Mailing Address - Fax:337-788-6598
Practice Address - Street 1:1305 CROWLEY RAYNE HWY
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-8202
Practice Address - Country:US
Practice Address - Phone:337-788-6407
Practice Address - Fax:337-788-6598
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN103384367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered