Provider Demographics
NPI:1083641286
Name:HEDER, LANE O (PA-C)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:O
Last Name:HEDER
Suffix:
Gender:M
Credentials:PA-C
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 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-397-6150
Mailing Address - Fax:801-397-6151
Practice Address - Street 1:3225 W GORDON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-6508
Practice Address - Country:US
Practice Address - Phone:801-397-6150
Practice Address - Fax:901-391-6151
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT378677-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000090400Medicare PIN
UT005503204Medicare ID - Type Unspecified