Provider Demographics
NPI:1558961607
Name:LANE, LARRY DEAN (PTA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:LANE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26046 LAUREL PASS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-2474
Mailing Address - Country:US
Mailing Address - Phone:916-798-4823
Mailing Address - Fax:
Practice Address - Street 1:2829 BABCOCK RD STE 700
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6015
Practice Address - Country:US
Practice Address - Phone:210-396-5270
Practice Address - Fax:210-396-5271
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2072503225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2072503OtherTEXAS BOARD OF PHYSICAL THERAPY EXAMINERS