Healthcare Provider Details

I. General information

NPI: 1700856085
Provider Name (Legal Business Name): ALEXIS GRACE LANE MD FACS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8055 VALENCIA ST
APTOS CA
95003-3954
US

IV. Provider business mailing address

8055 VALENCIA ST
APTOS CA
95003-3954
US

V. Phone/Fax

Practice location:
  • Phone: 831-688-8333
  • Fax: 831-688-8272
Mailing address:
  • Phone: 831-688-8333
  • Fax: 831-688-8272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG81601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: