Healthcare Provider Details

I. General information

NPI: 1578222188
Provider Name (Legal Business Name): LANCE WESLEY PORT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/10/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S DAISY ST
SALMON ID
83467
US

IV. Provider business mailing address

13613 N MANNING LN
POCATELLO ID
83202-5173
US

V. Phone/Fax

Practice location:
  • Phone: 208-756-6212
  • Fax:
Mailing address:
  • Phone: 208-479-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: