Healthcare Provider Details

I. General information

NPI: 1164615811
Provider Name (Legal Business Name): LANCE GATOR GAULT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 HERNDON AVE
CLOVIS CA
93611-6813
US

IV. Provider business mailing address

2740 HERNDON AVE
CLOVIS CA
93611-6813
US

V. Phone/Fax

Practice location:
  • Phone: 559-299-2608
  • Fax: 559-299-1341
Mailing address:
  • Phone: 559-299-2608
  • Fax: 559-299-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A10128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: