Provider Demographics
NPI:1851539084
Name:WISSMAN, LANCE REED (DPM)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:REED
Last Name:WISSMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19555 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6813
Mailing Address - Country:US
Mailing Address - Phone:623-572-3454
Mailing Address - Fax:623-572-3449
Practice Address - Street 1:19389 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6500
Practice Address - Country:US
Practice Address - Phone:623-537-6000
Practice Address - Fax:623-537-6014
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0568213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist