Basic Information
| Provider Information | |||||||||
| NPI: | 1881154490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | DEVIN | ||||||||
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| OtherLastName: | SHORT | ||||||||
| OtherFirstName: | MOLLY | ||||||||
| OtherMiddleName: | DEVIN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1409 RODEN BLVD | ||||||||
| Address2: | |||||||||
| City: | SHEPPARD AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763111378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135455676 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2700 WAYNE MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275349494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197361110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2019 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.