Provider Demographics
NPI:1578965208
Name:LANE, RANDY E (PA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:E
Last Name:LANE
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:PO BOX 71367
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-1367
Mailing Address - Country:US
Mailing Address - Phone:229-435-0525
Mailing Address - Fax:229-434-9827
Practice Address - Street 1:2311 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3183
Practice Address - Country:US
Practice Address - Phone:229-435-0525
Practice Address - Fax:229-434-9827
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant