MEDICARE: JEFFERY LANE JR. AU.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist

General Provider Information

NPI Number	:	1104318997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERY LANE JR. AU.D.

Provider Business Mailing Address
First Line	:	2700 S WOODLANDS VILLAGE BLVD STE 300-409
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-7114
Country	:	US
Telephone Number	:	928-522-0500
Fax Number	:	855-433-1122

Provider Business Practice Location Address
First Line	:	1330 N RIM DR STE B
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3138
Country	:	US
Telephone Number	:	928-522-0500
Fax Number	:	855-433-1122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	06/06/2018

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