Provider Demographics
NPI:1093010001
Name:HASELTINE, LANCE FAY (MD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:FAY
Last Name:HASELTINE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24521 POQUETTE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-9240
Mailing Address - Country:US
Mailing Address - Phone:612-991-4889
Mailing Address - Fax:
Practice Address - Street 1:24521 POQUETTE LAKE RD
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-9240
Practice Address - Country:US
Practice Address - Phone:612-991-4889
Practice Address - Fax:715-569-8698
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-22
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33541208D00000X
WI35039-20208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice