Basic Information
| Provider Information | |||||||||
| NPI: | 1245684398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLDMAN | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | DONAVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | POST OFFICE BOX 190 | ||||||||
| Address2: | |||||||||
| City: | ST. STEPHENS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078560470 | ||||||||
| FaxNumber: | 3078574383 | ||||||||
| Practice Location | |||||||||
| Address1: | #24 GREAT PLAINS ROAD | ||||||||
| Address2: | |||||||||
| City: | ARAPAHOE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078560470 | ||||||||
| FaxNumber: | 3078574383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.