Healthcare Provider Details

I. General information

NPI: 1952452492
Provider Name (Legal Business Name): LAWRENCE EDWIN CHANCE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH NORTHERN NAVAJO MEDICAL CENTER
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160 NORTHERN NAVAJO MEDICAL CENTER
SHIPROCK NM
87420
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax: 907-966-8606
Mailing address:
  • Phone: 505-368-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3780
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: