Healthcare Provider Details

I. General information

NPI: 1992711766
Provider Name (Legal Business Name): LANE C PETERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27810 SUMMERGATE BLVD
WESLEY CHAPEL FL
33544-6919
US

IV. Provider business mailing address

27810 SUMMERGATE BLVD
WESLEY CHAPEL FL
33544-6919
US

V. Phone/Fax

Practice location:
  • Phone: 813-388-2948
  • Fax: 813-388-6827
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number05-34066
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS17115
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: