Provider Demographics
NPI:1770727497
Name:BANNON, LAUREN LANE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:LANE
Last Name:BANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:DEAN
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4517 SOUTHLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3280
Mailing Address - Country:US
Mailing Address - Phone:205-985-4111
Mailing Address - Fax:
Practice Address - Street 1:4517 SOUTHLAKE PKWY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3280
Practice Address - Country:US
Practice Address - Phone:205-985-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-652363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
102I971861Medicare PIN