Healthcare Provider Details

I. General information

NPI: 1619937703
Provider Name (Legal Business Name): BRYAN T LANTZ PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 BELMONT AVE
BRATTLEBORO VT
05301-3498
US

IV. Provider business mailing address

241 ELM ST
CLAREMONT NH
03743-2026
US

V. Phone/Fax

Practice location:
  • Phone: 802-251-8611
  • Fax: 802-251-8419
Mailing address:
  • Phone: 603-542-7666
  • Fax: 603-542-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0486P
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0550030669
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: