Provider Demographics
NPI:1477551935
Name:LANE, CAMERON A (DPT)
Entity Type:Individual
Prefix:MR
First Name:CAMERON
Middle Name:A
Last Name:LANE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W. MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2453
Mailing Address - Country:US
Mailing Address - Phone:479-967-9657
Mailing Address - Fax:479-967-9658
Practice Address - Street 1:3016 W. MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2453
Practice Address - Country:US
Practice Address - Phone:479-967-9657
Practice Address - Fax:479-967-9658
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136073721Medicaid
AR136075742Medicaid
AR136073721Medicaid
AR5C105Medicare ID - Type UnspecifiedGROUP