Provider Demographics
NPI:1194758037
Name:LANCE, SUSAN (PAC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LANCE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:ATTN: MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14211 WHITE CREEK AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8168
Practice Address - Country:US
Practice Address - Phone:616-252-6320
Practice Address - Fax:616-252-6360
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN26620006Medicare PIN
MIP28256Medicare UPIN