Provider Demographics
NPI:1639407752
Name:LANE, NICHALAS FRANCIS (DPT)
Entity Type:Individual
Prefix:
First Name:NICHALAS
Middle Name:FRANCIS
Last Name:LANE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5111 N SCOTTSDALE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-7075
Mailing Address - Country:US
Mailing Address - Phone:480-990-1379
Mailing Address - Fax:480-423-8458
Practice Address - Street 1:5111 N SCOTTSDALE RD
Practice Address - Street 2:SUITE #100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-7075
Practice Address - Country:US
Practice Address - Phone:480-990-1379
Practice Address - Fax:480-423-8458
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8755225100000X
2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
036551Medicare PIN
036551Medicare UPIN