Healthcare Provider Details

I. General information

NPI: 1700330149
Provider Name (Legal Business Name): LANCE MARTIN STANG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2016
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 NE BROADWAY ST
PORTLAND OR
97232-1212
US

IV. Provider business mailing address

1455 NW IRVING ST STE 600
PORTLAND OR
97209-2277
US

V. Phone/Fax

Practice location:
  • Phone: 844-966-6777
  • Fax:
Mailing address:
  • Phone: 620-375-2233
  • Fax: 620-375-4954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60960296
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: