Provider Demographics
NPI:1700330149
Name:STANG, LANCE MARTIN (PA-C)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:MARTIN
Last Name:STANG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 NW IRVING ST STE 600
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2277
Mailing Address - Country:US
Mailing Address - Phone:620-375-2233
Mailing Address - Fax:620-375-4954
Practice Address - Street 1:606 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1212
Practice Address - Country:US
Practice Address - Phone:844-966-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-14
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA60960296363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA184907OtherOREGON MEDICAL BOARD