Healthcare Provider Details

I. General information

NPI: 1629419619
Provider Name (Legal Business Name): JOHN E LANIER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 PLEASANT PLAINS EXT RD
JACKSON TN
38305-6087
US

IV. Provider business mailing address

PO BOX 12197
JACKSON TN
38308-0136
US

V. Phone/Fax

Practice location:
  • Phone: 731-984-8400
  • Fax:
Mailing address:
  • Phone: 731-984-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2357
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: