Provider Demographics
NPI:1285344986
Name:AUSTELL, LANE CLEMENTS (PA-C)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:CLEMENTS
Last Name:AUSTELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S 52ND ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8610
Mailing Address - Country:US
Mailing Address - Phone:901-517-1434
Mailing Address - Fax:479-271-2133
Practice Address - Street 1:1000 S 52ND ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8610
Practice Address - Country:US
Practice Address - Phone:479-271-9607
Practice Address - Fax:479-271-2133
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5312363A00000X
ARPA-1163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant