Healthcare Provider Details

I. General information

NPI: 1467680983
Provider Name (Legal Business Name): JOSHUA ALTON LANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 11/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3736 MIKE PADGETT HWY STE A
AUGUSTA GA
30906-0720
US

IV. Provider business mailing address

1245 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1807
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-0389
  • Fax: 888-977-2990
Mailing address:
  • Phone: 706-868-0389
  • Fax: 706-651-0729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number65698
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: