Individual
LANCE WESLEY PORT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
103 S DAISY ST, SALMON, ID 83467
(208) 756-6212
Mailing address
13613 N MANNING LN, POCATELLO, ID 83202-5173
(208) 479-7678
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
—
Other
Enumeration date
12/10/2021
Last updated
12/10/2021
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