Provider Demographics
NPI:1033192620
Name:LANE, SUSAN MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:LANE
Suffix:
Gender:F
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:PO BOX 202149
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-2149
Mailing Address - Country:US
Mailing Address - Phone:907-258-2149
Mailing Address - Fax:907-258-2147
Practice Address - Street 1:2801 DEBARR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2932
Practice Address - Country:US
Practice Address - Phone:907-258-2149
Practice Address - Fax:907-258-2147
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5844163W00000X
AK23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRNA0028Medicaid
AK430047155OtherMEDICARE RAILROAD
AK430047155OtherMEDICARE RAILROAD
S16722Medicare UPIN