Basic Information
| Provider Information | |||||||||
| NPI: | 1881105088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANFORD | ||||||||
| FirstName: | CLINT | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 703 S FLEISHEL AVE STE 5000 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036067525 | ||||||||
| FaxNumber: | 9036067284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2017 | ||||||||
| LastUpdateDate: | 02/09/2018 | ||||||||
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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 | 363L00000X | AP135380 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-123 | 01 | TX | TRICARE | OTHER | 378693101 | 05 | TX | MEDICAID | 8HY590 | 01 | TX | BCBS | OTHER | P01938179 | 01 | TX | MEDICARE RAIL ROAD | OTHER | MEDICARE | 01 | TX | 616096YMAF | OTHER |