Provider Demographics
NPI:1013541341
Name:LANE, KIRT (CPC)
Entity Type:Individual
Prefix:
First Name:KIRT
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:360-200-6736
Practice Address - Street 1:1408 12TH AVENUE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3822
Practice Address - Country:US
Practice Address - Phone:360-998-3050
Practice Address - Fax:360-200-6736
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2154878Medicaid