Provider Demographics
NPI:1639156631
Name:LANE, LAURIE GENE (PC-C)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:GENE
Last Name:LANE
Suffix:
Gender:F
Credentials:PC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:CO
Mailing Address - Zip Code:81425-0529
Mailing Address - Country:US
Mailing Address - Phone:970-323-6141
Mailing Address - Fax:970-249-8421
Practice Address - Street 1:308 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:CO
Practice Address - Zip Code:81425
Practice Address - Country:US
Practice Address - Phone:970-323-6141
Practice Address - Fax:970-249-8421
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07142003Medicaid
CO07142003Medicaid
COP53800Medicare UPIN