Provider Demographics
NPI:1114167335
Name:LANE, AMOS MART (DO)
Entity Type:Individual
Prefix:
First Name:AMOS
Middle Name:MART
Last Name:LANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1210
Mailing Address - Country:US
Mailing Address - Phone:304-388-7170
Mailing Address - Fax:304-388-1858
Practice Address - Street 1:3110 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1210
Practice Address - Country:US
Practice Address - Phone:304-388-7170
Practice Address - Fax:304-388-1858
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2476207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine