Provider Demographics
NPI:1851680763
Name:LANCE, CRAIG PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:PHILLIP
Last Name:LANCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3212
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 E MIEL DE LUNA AVE
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3810
Practice Address - Country:US
Practice Address - Phone:800-841-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2101972085R0204X
390200000X
NMMD2017-04862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program