Provider Demographics
NPI:1063776318
Name:ABERNATHY, LANCE
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:ABERNATHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 LOUETTA RD
Mailing Address - Street 2:STE 112
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-7021
Mailing Address - Country:US
Mailing Address - Phone:281-370-2020
Mailing Address - Fax:281-251-2705
Practice Address - Street 1:311 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3348
Practice Address - Country:US
Practice Address - Phone:423-272-2020
Practice Address - Fax:423-272-5886
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8351T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0618002159OtherVIRGINIA STATE LICENSE