Provider Demographics
NPI:1447245105
Name:LANASA, ANTHONY V (MD)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:V
Last Name:LANASA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12272 US HIGHWAY 98 W
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550-6939
Mailing Address - Country:US
Mailing Address - Phone:850-269-0662
Mailing Address - Fax:850-269-0745
Practice Address - Street 1:12272 US HIGHWAY 98 W
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-6939
Practice Address - Country:US
Practice Address - Phone:850-269-0662
Practice Address - Fax:850-269-0745
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1186104Medicaid
LA1186104Medicaid
LA53459B920Medicare ID - Type Unspecified