Provider Demographics
NPI:1417949330
Name:LANIER, GREGORY D (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:LANIER
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 1:36951 COOK ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-6082
Mailing Address - Country:US
Mailing Address - Phone:760-342-8444
Mailing Address - Fax:760-342-8544
Practice Address - Street 1:1405 HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2107
Practice Address - Country:US
Practice Address - Phone:931-954-1020
Practice Address - Fax:833-441-2291
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4459363AM0700X
CAPA11273363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR23377Medicare UPIN
CA0PA112730Medicare PIN