Provider Demographics
NPI:1740249523
Name:CLOUSE, LANCE GORDON (APRN)
Entity type:Individual
Prefix:MR
First Name:LANCE
Middle Name:GORDON
Last Name:CLOUSE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:MR
Other - First Name:LANCE
Other - Middle Name:GORDON
Other - Last Name:CLOUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 6577
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-0482
Mailing Address - Country:US
Mailing Address - Phone:479-410-2225
Mailing Address - Fax:479-410-9238
Practice Address - Street 1:623 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-3418
Practice Address - Country:US
Practice Address - Phone:479-410-2225
Practice Address - Fax:479-410-9238
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1386111N00000X
ARA004094363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR203917758Medicaid
AR157263718Medicaid
ARU58733Medicare UPIN