Provider Demographics
NPI:1093558173
Name:SUPNET, LANCE MICHAEL (DPT)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:MICHAEL
Last Name:SUPNET
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3099 WHITESAND DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3056
Mailing Address - Country:US
Mailing Address - Phone:408-513-5820
Mailing Address - Fax:
Practice Address - Street 1:4205 SAN FELIPE RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95135-1546
Practice Address - Country:US
Practice Address - Phone:408-238-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist