Provider Demographics
NPI:1578793584
Name:LANE, BARRETT DUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:BARRETT
Middle Name:DUSTIN
Last Name:LANE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7257 HAWKINS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3921
Mailing Address - Country:US
Mailing Address - Phone:817-735-9397
Mailing Address - Fax:817-735-8340
Practice Address - Street 1:7257 HAWKINS VIEW DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3921
Practice Address - Country:US
Practice Address - Phone:817-735-9397
Practice Address - Fax:817-735-8340
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06292363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical