Provider Demographics
NPI:1649530668
Name:BLAU, LANCE NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:NICHOLAS
Last Name:BLAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6725
Mailing Address - Country:US
Mailing Address - Phone:330-729-4298
Mailing Address - Fax:330-729-1897
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6725
Practice Address - Country:US
Practice Address - Phone:330-729-4298
Practice Address - Fax:330-729-1897
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17206208600000X
OH35.138164207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery