Provider Demographics
NPI:1982726584
Name:FORTINBERRY, LANEY W (PA-C)
Entity Type:Individual
Prefix:
First Name:LANEY
Middle Name:W
Last Name:FORTINBERRY
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 1:191 GOLDEN AUTUMN PL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4803
Mailing Address - Country:US
Mailing Address - Phone:281-814-0487
Mailing Address - Fax:
Practice Address - Street 1:314 SAWDUST RD
Practice Address - Street 2:SUITE 119
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2347
Practice Address - Country:US
Practice Address - Phone:281-292-3030
Practice Address - Fax:281-292-1418
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04300363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1982726584Medicaid