MEDICARE: LANA ELIZABETH FORMO PA-C

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	8307	AZ

General Provider Information

NPI Number	:	1396364261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANA ELIZABETH FORMO PA-C

Provider Business Mailing Address
First Line	:	4881 E GRANT RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-2704
Country	:	US
Telephone Number	:	520-829-6776
Fax Number	:	520-829-6661

Provider Business Practice Location Address
First Line	:	4582 N 1ST AVE STE 170
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-8607
Country	:	US
Telephone Number	:	520-829-6776
Fax Number	:	520-829-6661

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

Provider Enumeration Date	:	04/10/2020
Last Update Date	:	09/26/2024

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