Provider Demographics
NPI:1891775151
Name:FAGAN, LANCE WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:WILLIAM
Last Name:FAGAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3400
Mailing Address - Country:US
Mailing Address - Phone:208-667-1591
Mailing Address - Fax:208-676-8574
Practice Address - Street 1:1801 N 3RD ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3400
Practice Address - Country:US
Practice Address - Phone:208-667-1591
Practice Address - Fax:208-676-8574
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDIDP1029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805917800Medicaid
ID805917800Medicaid
IDU82111Medicare UPIN