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General NPI Number Information
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NPI Number | 1609144435
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Entity Type | Individual
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Provider Name | LAWRENCE JOSEPH VANTY JR. PA
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Gender | Male
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Dates
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Enumeration Date | 12/07/2011
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 2315 8TH ST
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City | LEWISTON
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State | ID
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Zip | 83501-7301
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Country | US
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Telephone | 208-298-3094
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Fax | 833-941-3874
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Provider Business Mailing Address
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Address Line | 2315 8TH ST
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City | LEWISTON
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State | ID
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Zip | 83501-7301
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Country | US
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Telephone | 208-298-3094
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Fax | 833-941-3874
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA-953
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License Number State | ID
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