Provider Demographics
NPI:1013023738
Name:LANE, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 MEMORIAL ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-2504
Mailing Address - Country:US
Mailing Address - Phone:509-786-2010
Mailing Address - Fax:509-788-1794
Practice Address - Street 1:820 MEMORIAL ST STE 1
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-2504
Practice Address - Country:US
Practice Address - Phone:509-786-2010
Practice Address - Fax:509-788-1794
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
911019392OtherCOMMERCIAL
WA9392LAOtherREGENCE
WA8142218OtherCHPW
1306897681OtherNPI PROSSER MEMORIAL
WA8142218Medicaid
WA0200684OtherL & I
WA8142218OtherCHPW
WAE17463Medicare UPIN
E17463Medicare UPIN
WA0200684OtherL & I
WA8853887Medicare Oscar/Certification