Provider Demographics
NPI:1477548188
Name:LANE, KIM RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:RAE
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 15TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2700
Mailing Address - Country:US
Mailing Address - Phone:303-776-5820
Mailing Address - Fax:303-776-3302
Practice Address - Street 1:630 15TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2700
Practice Address - Country:US
Practice Address - Phone:303-776-5820
Practice Address - Fax:303-776-3302
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2010-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
CO36341174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77633024Medicaid
COH09603Medicare UPIN
CO488268Medicare ID - Type Unspecified