Provider Demographics
NPI:1700856085
Name:LANE, ALEXIS GRACE (MD FACS)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:GRACE
Last Name:LANE
Suffix:
Gender:F
Credentials:MD FACS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8055 VALENCIA ST
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3954
Mailing Address - Country:US
Mailing Address - Phone:831-688-8333
Mailing Address - Fax:831-688-8272
Practice Address - Street 1:8055 VALENCIA ST
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3954
Practice Address - Country:US
Practice Address - Phone:831-688-8333
Practice Address - Fax:831-688-8272
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG81601207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G816010OtherBLUE SHIELD
CAH28031Medicare UPIN
CA00G816010OtherBLUE SHIELD