Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | 000000G81602 | CA |
NPI | 1043390172 |
---|---|
Provider Name | Dr. John Shackelford Lane III |
First Address | San Diego, CA 92103-7403 |
Second Address | San Diego, CA 92103-9000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2006 |
Last Update Date | 04/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H59478 | (02) | CA |