Provider Demographics
NPI:1902086119
Name:WEATHERS, LANCE WADE (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:WADE
Last Name:WEATHERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2708 RIFE MEDICAL LANE
Mailing Address - Street 2:STE 220
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1452
Mailing Address - Country:US
Mailing Address - Phone:479-338-4400
Mailing Address - Fax:479-338-4445
Practice Address - Street 1:2708 RIFE MEDICAL LANE
Practice Address - Street 2:STE 220
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:479-338-4400
Practice Address - Fax:479-338-4445
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-7387207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5AQ07Medicare PIN
AR193142001Medicaid