Provider Demographics
NPI:1396364261
Name:FORMO, LANA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:ELIZABETH
Last Name:FORMO
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 1:4881 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2704
Mailing Address - Country:US
Mailing Address - Phone:520-829-6776
Mailing Address - Fax:520-829-6661
Practice Address - Street 1:4582 N 1ST AVE STE 170
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-8607
Practice Address - Country:US
Practice Address - Phone:520-829-6776
Practice Address - Fax:520-829-6661
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ8307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty