Provider Demographics
NPI:1720312168
Name:LANE, JOHN ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:LANE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:109 CASTLEBAY DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-6272
Mailing Address - Country:US
Mailing Address - Phone:910-725-9256
Mailing Address - Fax:
Practice Address - Street 1:2149 VALLEYGATE DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3668
Practice Address - Country:US
Practice Address - Phone:910-728-4410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-08114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant