Provider Demographics
NPI:1720291677
Name:GATEWOOD, LANCE BUTLER (MS, CCP)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:BUTLER
Last Name:GATEWOOD
Suffix:
Gender:M
Credentials:MS, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 W TELLURITE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-4192
Mailing Address - Country:US
Mailing Address - Phone:520-219-3822
Mailing Address - Fax:520-219-3822
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-5071
Practice Address - Country:US
Practice Address - Phone:520-626-6339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ940094-0297242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist