Healthcare Provider Details

I. General information

NPI: 1902434889
Provider Name (Legal Business Name): LANE HOLLISTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15790 PAUL VEGA MD DR
HAMMOND LA
70403-1436
US

IV. Provider business mailing address

2328 VESTAL AVE
LOS ANGELES CA
90026-2058
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-3066
  • Fax: 985-230-6652
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number331002
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: