Healthcare Provider Details

I. General information

NPI: 1386833713
Provider Name (Legal Business Name): EVAN LANTZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 N LAUGHLIN RD STE 103
SANTA ROSA CA
95403-9067
US

IV. Provider business mailing address

3663 N LAUGHLIN RD STE 103
SANTA ROSA CA
95403-9067
US

V. Phone/Fax

Practice location:
  • Phone: 707-528-7999
  • Fax:
Mailing address:
  • Phone: 707-528-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: