Healthcare Provider Details

I. General information

NPI: 1356650360
Provider Name (Legal Business Name): TABITHA MARIE LANE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2010
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S 9TH ST
CANON CITY CO
81212-4911
US

IV. Provider business mailing address

402 STAR RANCH RD
CANON CITY CO
81212-9831
US

V. Phone/Fax

Practice location:
  • Phone: 719-269-8820
  • Fax:
Mailing address:
  • Phone: 501-987-2932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0003062
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9120043
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003062
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: