Healthcare Provider Details

I. General information

NPI: 1770727497
Provider Name (Legal Business Name): LAUREN LANE BANNON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN DEAN LANE PA

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4517 SOUTHLAKE PKWY
HOOVER AL
35244-3280
US

IV. Provider business mailing address

4517 SOUTHLAKE PKWY
HOOVER AL
35244-3280
US

V. Phone/Fax

Practice location:
  • Phone: 205-985-4111
  • Fax:
Mailing address:
  • Phone: 205-985-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-652
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-652
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: