Provider Demographics
NPI:1750362554
Name:LARGE, LANCE BRANDON (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:BRANDON
Last Name:LARGE
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 1:1375 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-2099
Mailing Address - Country:US
Mailing Address - Phone:503-769-2641
Mailing Address - Fax:503-769-3797
Practice Address - Street 1:1375 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2099
Practice Address - Country:US
Practice Address - Phone:503-769-2641
Practice Address - Fax:503-769-3797
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD2310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023015Medicaid
OR023015Medicaid