Provider Demographics
NPI:1275714453
Name:LANE, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7338
Practice Address - Country:US
Practice Address - Phone:910-662-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1275714453Medicaid
NC8101324Medicaid
FLP43141Medicare UPIN
NC8101324Medicaid