Provider Demographics
NPI:1710230651
Name:LANE, SHELBY A (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:A
Last Name:LANE
Suffix:
Gender:F
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 1:3319 NE 15TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1709
Mailing Address - Country:US
Mailing Address - Phone:954-257-7859
Mailing Address - Fax:954-616-8063
Practice Address - Street 1:3319 NE 15TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1709
Practice Address - Country:US
Practice Address - Phone:954-257-7859
Practice Address - Fax:954-616-8063
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9106913363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG9675ZOtherMEDICARE ID-TYPE UNSPECIFIED