Provider Demographics
NPI:1881105088
Name:LANFORD, CLINT S (FNP-C)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:S
Last Name:LANFORD
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:703 S FLEISHEL AVE STE 5000
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2015
Practice Address - Country:US
Practice Address - Phone:903-606-7525
Practice Address - Fax:903-606-7284
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135380363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMEDICAREOther616096YMAF
TX378693101Medicaid
TX8HY590OtherBCBS
TXP01938179OtherMEDICARE RAIL ROAD
TX75-2616977-123OtherTRICARE