Provider Demographics
NPI:1003001579
Name:KEVIN LANE DO PA
Entity Type:Organization
Organization Name:KEVIN LANE DO PA
Other - Org Name:KEVIN LANE DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:FLANNERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-663-5111
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252-0359
Mailing Address - Country:US
Mailing Address - Phone:940-663-5111
Mailing Address - Fax:940-663-5899
Practice Address - Street 1:404 MERCER ST
Practice Address - Street 2:
Practice Address - City:QUANAH
Practice Address - State:TX
Practice Address - Zip Code:79252-4026
Practice Address - Country:US
Practice Address - Phone:940-663-5111
Practice Address - Fax:940-663-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE87143Medicare UPIN
TX00105YMedicare Oscar/Certification