MEDICARE: LANEY W FORTINBERRY 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	363AM0700X	Medical Physician Assistant	PA04300	TX
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1982726584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANEY W FORTINBERRY PA-C

Provider Business Mailing Address
First Line	:	191 GOLDEN AUTUMN PL
Second Line	:
City	:	THE WOODLANDS
State	:	TX
Zip	:	77384-4803
Country	:	US
Telephone Number	:	281-814-0487
Fax Number	:

Provider Business Practice Location Address
First Line	:	314 SAWDUST RD
Second Line	:	SUITE 119
City	:	THE WOODLANDS
State	:	TX
Zip	:	77380-2347
Country	:	US
Telephone Number	:	281-292-3030
Fax Number	:	281-292-1418

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	11/30/2022

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Directions to “ LANEY W FORTINBERRY PA-C” Practice Location

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