Provider Demographics
NPI:1003622234
Name:LANE, JUSTIN ANTHONY
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:LANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WOODLAKE LN # 304
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-1183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304 WOODLAKE LN # 304
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1183
Practice Address - Country:US
Practice Address - Phone:313-574-8845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2012088207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services