Provider Demographics
NPI:1861520637
Name:LANTZ, RUSSELL GUY (PA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:GUY
Last Name:LANTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 HUNTERS WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2103
Mailing Address - Country:US
Mailing Address - Phone:757-650-9477
Mailing Address - Fax:
Practice Address - Street 1:2010 OLD GREENBRIER RD STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2619
Practice Address - Country:US
Practice Address - Phone:757-361-6634
Practice Address - Fax:757-361-6635
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110000082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00203610Medicare ID - Type UnspecifiedRAILROAD
VA006405B88Medicare ID - Type UnspecifiedTRAIBLAZERS