Provider Demographics
NPI:1396367264
Name:LANE, BRANDON ALLEN
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ALLEN
Last Name:LANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 E HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-2624
Mailing Address - Country:US
Mailing Address - Phone:417-268-8593
Mailing Address - Fax:
Practice Address - Street 1:1423 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1917
Practice Address - Country:US
Practice Address - Phone:417-269-8592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic