Provider Demographics
NPI:1487708103
Name:WIIST, LANCE JORDAN (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:JORDAN
Last Name:WIIST
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 1:761 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:770-513-4000
Mailing Address - Fax:
Practice Address - Street 1:761 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:770-513-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033754207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00446993AMedicaid
GA619666OtherBLUE CROSS BLUE SHIELD GA
GA160054732OtherPALMETTO GBA RAILROAD
GA000446993AOtherPEACHSTATE
GA00446993AOtherWELLCARE
GA00446993AMedicaid
GAC69162Medicare UPIN