Provider Demographics
NPI:1073719233
Name:LANE, LAURIE A (PTA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:LANE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 W GERMAN ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-2135
Mailing Address - Country:US
Mailing Address - Phone:315-866-3330
Mailing Address - Fax:311-586-6654
Practice Address - Street 1:690 W GERMAN ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2135
Practice Address - Country:US
Practice Address - Phone:315-866-3330
Practice Address - Fax:311-586-6654
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0003731225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant