Provider Demographics
NPI:1144205220
Name:LANE, JEREMY JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:LANE
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3931 LOUISIANA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-5000
Mailing Address - Country:US
Mailing Address - Phone:952-993-3230
Mailing Address - Fax:952-993-1748
Practice Address - Street 1:3931 LOUISIANA AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-5000
Practice Address - Country:US
Practice Address - Phone:952-993-3230
Practice Address - Fax:952-993-1748
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9937363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q35799Medicare UPIN