Provider Demographics
NPI:1629419619
Name:LANIER, JOHN E (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
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:PO BOX 12197
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0136
Mailing Address - Country:US
Mailing Address - Phone:731-984-8400
Mailing Address - Fax:
Practice Address - Street 1:2075 PLEASANT PLAINS EXT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6087
Practice Address - Country:US
Practice Address - Phone:731-984-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2357363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical