Healthcare Provider Details

I. General information

NPI: 1902657356
Provider Name (Legal Business Name): LANCE CHRISTIAN ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CHERRY ST NE
MARIETTA GA
30060-7205
US

IV. Provider business mailing address

1045 OLD PEACHTREE RD NW APT 2223
SUWANEE GA
30024-5067
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-5700
  • Fax:
Mailing address:
  • Phone: 434-942-9145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: