Provider Demographics
NPI:1558343681
Name:LANE, RANDALL CURTIS (CERTIFIED PHYSICIAN)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:CURTIS
Last Name:LANE
Suffix:
Gender:M
Credentials:CERTIFIED PHYSICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 S. WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670
Mailing Address - Country:US
Mailing Address - Phone:903-938-1146
Mailing Address - Fax:903-927-2434
Practice Address - Street 1:811 S. WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670
Practice Address - Country:US
Practice Address - Phone:903-938-1146
Practice Address - Fax:903-927-2434
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04303363A00000X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
8G0613Medicare ID - Type Unspecified
TXQ54127Medicare UPIN
Q54127Medicare UPIN