Provider Demographics
NPI:1356650360
Name:LANE, TABITHA MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:MARIE
Last Name:LANE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1890 SW HEALTH PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0473
Mailing Address - Country:US
Mailing Address - Phone:239-449-7979
Mailing Address - Fax:239-593-3356
Practice Address - Street 1:1890 SW HEALTH PKWY STE 205
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0473
Practice Address - Country:US
Practice Address - Phone:239-449-7979
Practice Address - Fax:239-593-3356
Is Sole Proprietor?:No
Enumeration Date:2010-09-26
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO3062363A00000X
FL9120043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMEDICAREOtherMEDIARE PENDING