Provider Demographics
NPI:1003827478
Name:LANE, JASON TODD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:TODD
Last Name:LANE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 PARKLANE RD
Mailing Address - Street 2:APT 7D
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-4904
Mailing Address - Country:US
Mailing Address - Phone:601-347-2739
Mailing Address - Fax:
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-5500
Practice Address - Fax:601-249-1709
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852446367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09724257Medicaid