Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | DO4314 | FL |
NPI | 1205058914 |
---|---|
Provider Name | Lane Shaw |
First Address | Lecanto, FL 34461-8657 |
Second Address | Inverness, FL 34453-3216 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 09/07/2007 |