Provider Demographics
NPI:1376628388
Name:LANE, KENNETH S (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2754 COMPASS DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8714
Mailing Address - Country:US
Mailing Address - Phone:970-254-1686
Mailing Address - Fax:
Practice Address - Street 1:2021 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2980
Practice Address - Country:US
Practice Address - Phone:970-242-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27953207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00208434OtherRR MEDICARE
COLAN27877OtherBCBS
COLAN27877OtherBCBS
CO494288Medicare ID - Type Unspecified
P00208434OtherRR MEDICARE