Provider Demographics
NPI:1740231646
Name:LANE, DEBRA A (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 E BROADWAY BLVD
Mailing Address - Street 2:HEALTHSTAR PHYSICIANS STE C
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760
Mailing Address - Country:US
Mailing Address - Phone:865-475-9062
Mailing Address - Fax:865-475-9063
Practice Address - Street 1:657 E BROADWAY BLVD
Practice Address - Street 2:HEALTHSTAR PHYSICIANS STE C
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760
Practice Address - Country:US
Practice Address - Phone:865-475-9062
Practice Address - Fax:865-475-9063
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD40163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3333808Medicaid
TN3333808Medicaid
TN3333808Medicare ID - Type Unspecified